Classifications

• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K31/00—Medicinal preparations containing organic active ingredients
  • A61K31/33—Heterocyclic compounds
  • A61K31/335—Heterocyclic compounds having oxygen as the only ring hetero atom, e.g. fungichromin
  • A61K31/35—Heterocyclic compounds having oxygen as the only ring hetero atom, e.g. fungichromin having six-membered rings with one oxygen as the only ring hetero atom
  • A61K31/352—Heterocyclic compounds having oxygen as the only ring hetero atom, e.g. fungichromin having six-membered rings with one oxygen as the only ring hetero atom condensed with carbocyclic rings, e.g. methantheline 
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K31/00—Medicinal preparations containing organic active ingredients
  • A61K31/33—Heterocyclic compounds
  • A61K31/395—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins
  • A61K31/435—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins having six-membered rings with one nitrogen as the only ring hetero atom
  • A61K31/4353—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins having six-membered rings with one nitrogen as the only ring hetero atom ortho- or peri-condensed with heterocyclic ring systems
  • A61K31/436—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins having six-membered rings with one nitrogen as the only ring hetero atom ortho- or peri-condensed with heterocyclic ring systems the heterocyclic ring system containing a six-membered ring having oxygen as a ring hetero atom, e.g. rapamycin
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K31/00—Medicinal preparations containing organic active ingredients
  • A61K31/70—Carbohydrates; Sugars; Derivatives thereof
  • A61K31/7042—Compounds having saccharide radicals and heterocyclic rings
  • A61K31/7048—Compounds having saccharide radicals and heterocyclic rings having oxygen as a ring hetero atom, e.g. leucoglucosan, hesperidin, erythromycin, nystatin, digitoxin or digoxin
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K45/00—Medicinal preparations containing active ingredients not provided for in groups A61K31/00 - A61K41/00
  • A61K45/06—Mixtures of active ingredients without chemical characterisation, e.g. antiphlogistics and cardiaca
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P25/00—Drugs for disorders of the nervous system
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P29/00—Non-central analgesic, antipyretic or antiinflammatory agents, e.g. antirheumatic agents; Non-steroidal antiinflammatory drugs [NSAID]
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P37/00—Drugs for immunological or allergic disorders
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P37/00—Drugs for immunological or allergic disorders
  • A61P37/02—Immunomodulators
  • A61P37/06—Immunosuppressants, e.g. drugs for graft rejection
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P43/00—Drugs for specific purposes, not provided for in groups A61P1/00-A61P41/00

Definitions

• anatomical blood barrier structures such as the Blood-Tissue barrier (BTB)
• BTB Blood-Tissue barrier
• pharmaceutical agents often cross the barrier causing systemic side-effects rather than a desired localized action.
• Prograf the market leading immunosuppressant for preventing transplant rejection has been reported to caused neurotoxicity, including tremor, headaches, and other changes in motor function, mental status, and sensory function, in approximately 55% or liver transplant recipients.
• Tremor occurred in 54% of Prograf- treated kidney transplant patients and 15% of heart transplant patients.
• Other immunosuppressants such as Cyclosporin, also cause neurotoxicity that leads to undesirable side effects
• Prograf has also been shown to cause, can cause acute and chronic nephrotoxicity.
• solid organ transplantation is increasing and grafts last longer than they used to - a kidney given in 2003 is expected to last 20 years- there is a need to find methods to decrease side effects that impinge on quality of life of patients.
• the invention provides methods, compositions, and kits for the use of blood-tissue barrier (BTB) transport protein modulator, e g , to reduce or eliminate a side effect and/or enhance a therapeutic effect of a calcineurin inhibitor
• BTB blood-tissue barrier
• compositions including a BTB transport protein modulator In some embodiment, the invention provides compositions including an effective amount of a calcmeu ⁇ n inhibitor and an amount of a BTB transport protein modulator sufficient to decrease a side effect of the calcineurin inhibitor.
• the invention provides a composition including a calcineurin inhibitor and a Blood-Tissue barrier (BTB) transport protein modulator, where the BTB transport protein modulator is present in an amount sufficient to enhance a therapeutic effect of the calcineurin inhibitor when the composition is administered to an animal
• the invention provides a composition including a calcineurin inhibitor and a Blood-Tissue barrier (BTB) transport protein modulator, where the BTB transport protein modulator is present m an amount sufficient to increase the concentration of the calcineurin inhibitor in a physiological compartment when the composition is administered to an animal
• the physiological compartment includes blood, lymph nodes, spleen, peyer's patches, lungs, and heart [0006]
• BTB transport protein includes an ABC transport protein
• the BTB transport protein modulator in the composition includes a BTB transport protein activator
• the BTB transport protein modulator m the composition includes a polyphenol
• the polyphenol includes a flavonoid
• the polyphenol includes quercetm, lsoquercetm, flavon, chrysin, apigenin, rhoifolm, diosmin, galangin, fisetm, morm, rutin, kaempierol, my ⁇ cetm, taxifo ⁇ in, narmgenm, na ⁇ ngm, hesperetin, nesperidin, chalcone, phioretm, phlo ⁇ zdin, genistein, biochanin A, catechm, and epicatechin
• the flavonoid is quercetm [0007]
• the BTB transport protein modulator decreases a side effect
• the BTB transport protein modulator decreases a central
• a pharmaceutical composition includes the composition of the invention and a pharmaceutically acceptable excipient
• a molar ratio of the calcmeu ⁇ n inhibitor and the BTB transport protein modulator is about 0 001 1 to about 10 1
• the calcineu ⁇ n inhibitor is present in an amount of about 0 1-1000 mg and the BTB transport protein modulator is present in an amount of about 10 to 1000 mg
• a kit includes the composition of the invention and instructions for use of the composition
• the invention provides methods utilizing BTB transport protein modulator
• the invention provides a method of treating a condition by administering to an animal suffering from the condition an effective amount of a calcineurm inhibitor and an amount of a BTB transport protein modulator sufficient to increase a therapeutic effect of the calcmeurm inhibitor
• the BTB transport protein modulator is a BTB protein transport activator
• the invention provides a method of treating a condition by administering to an animal suffering from the condition an effective amount of a calcmeurm inhibitor and an amount of a BTB transport protein modulator sufficient to reduce or eliminate a CNS effect of the calcmeurm inhibitor
• the modulator reduces or eliminates a plurality of CNS effects of the calcmeurm inhibitor
• the invention provides a method of treating a condition by administering to an animal suffering from the condition an effective amount of a calcmeurm inhibitor and an amount of a BTB transport protein modulator sufficient to reduce or eliminate a hepatic, pancreatic and/or gastrointestinal side effect of the calcmeurm inhibitor
• the modulator reduces or eliminates a plurality of hepatic, pancreatic and/or gastrointestinal side effects of the calcmeurm inhibitor
• the modulator reduces or eliminates a plurality of hepatic, pancreatic and/or gastrointestinal side effects of the
• the calcineurin inhibitor is present m an amount sufficient to exert a therapeutic effect and the BTB transport protem activator is present in an amount sufficient to decrease a side effect of the calcineurin inhibitor by an average of at least about 5%, compared to the effect without the BTB transport protein activator
• the administration is oral administration
• the side effect is a CNS side effect
• the CNS side effect is selected from the group consisting of tremors, headache, changes in motor function, changes in mental status, changes in sensory functions, seizures, insomnia, paresthesia, dizziness, coma and delirium
• the BTB transport protem modulator decreases a hepatic, pancreatic and/or gastrointestinal side effect
• the hepatic, pancreatic and/or gastrointestinal side effect is hepatic necrosis, hepatotoxicity, liver fatty,
• the calcineurm inhibitor is present in an amount sufficient to exert a therapeutic effect and the BTB transport protem modulator is present in an amount sufficient to increase the concentration of the calcineurm inhibitor in a physiological compartment
• the physiological compartment is selected from the group consisting of blood, lymph nodes, spleen, peyer's patches, lungs, and heart
• the invention provides a method of treating a condition by administering to an animal suffering from the condition an effective amount of tacrolimus and an amount of a BTB transport protein modulator sufficient to change the concentration of tacrolimus in a physiological compartment
• the physiological compartment is selected from the group consisting of blood, lymph nodes, spleen, peyer's patches, lungs, heart kidney, pancreas liver, and gull bladder
• the BTB transport modulator decrease the clearance of tacrolimus from a compartment where the drug is exerting therapeutic effect
• the BTB transport protem modulator includes an activator of P-gP
• the BTB transport protein modulator includes a polyphenol
• the polyphenol includes a flavonoid
• the polyphenol includes quercetm, lsoquercetm, flavon, chrysin, apigemn, rhoifohn, diosmin, galangin, f ⁇ setrn, mo ⁇ n, rutin, kaempferol, my ⁇ cetin, taxifolm, naringemn, narmgm, hesperetin, hespe ⁇ din, chalcone, phloretin, phlorizdm, ge concludedm, biochanin A, catechin, or epicatechm
• the flavonoid includes quercetm or other substituted analogs of naturally-occurrmg (bio)f
• the administration includes single or multiple doses of said calcmeu ⁇ n inhibitor and single or multiple doses of said BTB transport protein modulator In some embodiments of the method of the invention, the administration comprising simultaneous administration of said calcineurm inhibitor and said BTB transport protein modulator in the same dosage form, simultaneous administration in separate dosage forms, or separate administration In some embodiments of the method of the invention, the administration includes simultaneous administration of the calcmeurm inhibitor and the BTB transport protein modulator in the same dosage form In some embodiments of the method of the invention, the administration is oral administration
• FIG 1 depicts blood brain barrier (BBB) and blood-cerebrospmal fluid (CSF) barrier which regulates access to the brain
• Figure 2 depicts various transporters that regulate rate of brain permeation for compounds with varying lipophilicity
• Figure 3 provides an illustration of active transporters for both influx and efflux
• Figure 8 shows the effect of quercetm and tacrolimus on response of mouse spleen cells to concanavahn A at a high cell concentration
• Figure 9 shows the effect of quercetm and tacrolimus on response of mouse spleen cells to concanavahn A at a low cell concentration
• Figure 10 shows the effect of quercetm and tacrolimus on response of mouse spleen cells to LPS at a high cell concentration
• Figure 11 shows the effect of quercetm and tacrolimus on response of mouse spleen cells to LPS at a low cell concentration
• Figure 12 shows the effect of vehicle treatment on mitogen responses at a high cell concentration
• Figure 13 shows the effect of vehicle treatment on mitogen responses at a low cell concentration
• Figure 14 depicts the effect of different doses of quercetm on FK 506 inhibition of lymphocyte proliferation after Con A stimulation at a high cell concentration
• Figure 15 depicts the effect of different doses of quercetm on FK 506 inhibition of lymphocyte proliferation after Con A stimulation at a low cell concentration
• Figure 16 depicts a table with the pharmacokinetics parameters of FK 506 in male Lewis rats after 1 mg/kg i v. administration
• Figure 17 depicts the levels of FK 506 m plasma at different time points after quercetm administration
• Figure 18 depicts the calculated AUC (0-infimty) of rats treated with FK 506 i v and Quercentin i p at two different concentrations of quercetm
• Figure 19 depicts a table with non compartmental calculations of rats treated with FK 506 i v and
• Figure 20 depicts the levels of FK 506 m whole blood at different time points after i p administration of quercetm at two different concentrations of quercetm
• the invention provides compositions and methods utilizing an agent that modulates an effect, e g , that reduces or eliminates a side effect and/or increases a therapeutic effect associated with calcineu ⁇ n inhibitor treatment
• the invention provides compositions and methods utilizing an agent that changes the concentration of a calcineu ⁇ n inhibitor in a physiological compartment
• the invention provides compositions and methods utilizing a combination of a calcineu ⁇ n inhibitor and an agent that reduces or eliminates a side effect associated with calcineurin inhibitor treatment
• the invention provides compositions and methods utilizing a combination of a calcineurm inhibitor and an agent that increases or en ances a t erapeutic effect associate wit ca cmeu ⁇ n inhibitor treatment
• the invention provides compositions and methods utilizing a combination of a calcmeunn inhibitor and an agent that changes the concentration of a calcmeurin inhibitor in a physiological compartment Examples of calcmeunn inhibitors
• the access to the bram is controlled by at least two barriers, i e , blood bram barrier (BBB) and blood- cerebrospinal fluid (CSF) barrier (see FIG 1)
• BBB blood bram barrier
• CSF blood- cerebrospinal fluid
• the term "blood bram-bamer” can encompass the blood-brain and blood-CSF barriers, unless otherwise indicated
• the methods and compositions described herein are suitable for modulating the access of drugs into the brain
• the methods and compositions involve the modification of the blood brain barrier and/or blood-CSF barrier to prevent the entry of drugs into the central nervous system (CNS), e g , by promoting efflux of the drugs from the CNS
• the compositions and methods of the invention utilize a modulator of a blood brain-barrier transport protein
• the compositions and methods of the invention utilize an activator of a blood brain-barrier transport protein
• the blood bram barrier is formed by tight intercellular junctions of bram capillary endothelial cells
• the junctions are sealed by zonulae occludentes and tight junctions
• the capillaries are covered by a continuous basal membrane enclosing pericytes, an intermittent cell layer, and the outer basal membrane is contacted by astrocytes
• the electrical resistance across the endothelium is high, about 1500 to about 2000 ⁇ /cm 2
• the blood brain barrier regulates the transfer of substances between circulating blood and brain by facilitated transport and/or facilitated efflux
• the interface on both luminal and ablummal surfaces contain physical and metabolic transporter components
• the exchange of substances between circulating blood and brain can be determined by evaluating octanol/H 2 0 partition coefficient, facilitated transport, and/or facilitated efflux
• the methods of measuring blood brain barrier integrity can be used to identify suitable central nervous system modulators for use in the methods and compositions desc ⁇ bed herein
• hydrophilic nutrients such as glucose and ammo acids
• compounds with low lipophihcity are pumped away from the physiological compartments by, for example, xenobiotic efflux transporters
• transporters are preferably modulated by the methods and compositions described herein to prevent entry of compounds and drugs into the central nervous system
• the blood CSF barrier is formed by the tight junctions of the epithelium of the choroid plexus and arachnoid membrane surrounding the brain and spinal cord It is involved in micronutrient extraction, clearance of metabolic waste, and transport of drugs
• Mechanisms and routes of compounds into and out of bram include - paracellular aqueous pathway for water soluble agents, transcellular lipophilic pathway for lipid soluble agents, transport proteins for glucose, amino acids, purines, etc , specific receptor mediated endocytosis for insulin, transferrin, etc , adsorptive endocytosis for albumin, other plasma proteins, etc , and transporters (e g , blood-brain barrier transport proteins) such as P- glycoprotein (P-gP), multi-drug resistance proteins (MRP), organic anion transporter (OAT) efflux pumps, gamma- aminobuty ⁇ c acid (GABA) transporters and other transporters that modulate transport of drugs and other xeno iotics.
• transporters e g , blood-brain barrier transport proteins
• P-gP P- glycoprotein
• MRP multi-drug resistance proteins
• OAT organic anion transporter
• GABA gamma- aminobuty ⁇ c acid
• compositions o t e invention may invo ve mo u ation o one or more or these transporters
• the central nervous system modulators affect one or more of these mechanisms and routes to extrude drugs from the central nervous system
• compositions described herein also modulate other CNS barriers, such as neuronal transport barriers, as well as other CNS barriers.
• the blood bram barrier is modulated with a nitric oxide synthase (NOS) inhibitor.
• NOS nitric oxide synthase
• the NOS inhibitor is a NOS-3 inhibitor
• NOS-3 inhibitors include analogs of
• L-arginine such as N G -Monomethyl-L-Argimne (L-NMMA), L-N-Methyl Arginine (L-NMA), N G -Nitro-L-
• the invention provides methods and compositions that modulate ATP Binding Cassette (ABC) transport proteins ABC transport proteins are a superfarmly of membrane transporters with similar structural features. These transport proteins are widely distributed in prokaryotic and eukaryotic cells They are critical in the maintenance of barrier to foreign molecules and removal of waste from privileged spaces, and may be overexpressed in certain glial tumors conferring drug resistance to cytotoxic drugs. 48 members of the superfarmly are described There are 7 major subfamilies, which include ABC A-G.
• Subfamilies C, B, and G play a role m transport activity at blood brain barrier and blood-CSF barrier
• ABC A substrates include lipids and cholesterol
• ABC B transporters include P-glycoprotein (P-gP) and other multi drug resistance proteins (MRPs)
• ABC C contains MRP proteins
• ABC E is expressed in ovary, testis and spleen
• ABC G contains breast cancer resistance protein (BCRP).
• P-gP P-glycoprotein
• MRPs multi drug resistance proteins
• BCRP breast cancer resistance protein
• OAT organic anion transport systems
• P-gP organic anion transport systems
• GABA transporters GAT- 1 and GAT2/BGT-1
• Substrate compounds for OATs mclude opiate peptides, including enkephalin and deltorphm II, anionic compounds, indomethacm, salicylic acid and cimetidme OATs are inhibited by baclofen, tagamet, indomethacin, etc and transport HVA (dopamine metabolite) and metabolites of norepinephrine, epinephrine, 5- HT3, and histamine
• HVA dopamine metabolite
• GABA transporters are Na and Cl dependent, and are specific for GABA, taurine, ⁇ alanine, betaine, and nipecotic acid
• GAT2 transporters are localized to abluminal and luminal surfaces of capillary endothelial cells
• GAT-I is localized to the outside of neurons and gha GABA-transporter substrates include lorazepam, midazolam, diazepam, klonazepam and baclofen
• Probenicid inhibits luminal membrane GABA transporters from capillary endothelial cells GAT-I is inhibited by Tiagabme
• the invention provides methods and compositions that modulate P-gP, e g , that activate P-gP P-gP, also known as ABCB 1 , forms a protective barrier to pump away by excreting compounds into bile, urine, and intestinal lumen
• P-gP P-gP
• e g that activate P-gP P-gP
• ABCB 1 forms a protective barrier to pump away by excreting compounds into bile, urine, and intestinal lumen
• Three isoforms have been identified in rodents (mdrla, mdrlb, mdr2) and two in humans (MDRl and MDR2) It is expressed in epithelium of the bram choroid plexus (which forms the blood— cerebrospinal fluid barrier), as well as on the luminal surface of blood capillaries of the bram (blood-brain barrier) and other tissues known to have Blood-Tissue barriers, such as the placenta, the ovaries, and the testes [0057] In
• P-gP substrates include molecules that tend to be lipophilic, planar molecules or uncharged or positively charged molecules
• Non-limiting examples include organic cations, weak organic bases, organic anions and other uncharged compounds, including polypeptides and peptide derivatives, aldosterone, anthracyclmes, colchicine, dexamethasone, digoxin, diltiazem, HIV protease inhibitors, loperamide, MTX, morphine, ondansetron, phenytom and /3-blockers
• Inhibitors of P-gP include quimdine, verapamil, rifampin, PSC 833 (see Schinkel, J. CIm Invest ,
• Multi-drug resistance protein (MRP) substrates include acetaminophen glucuronide, protease inhibitors, methotrexate and ampicilhn Inhibitors of MRP include buthionine sulphoximine, an inhibitor of glutathione biosynthesis
• the placenta a physical barrier that separates the blood supply of the mother and fetus
• the major function of the placenta is to transfer nutrients and oxygen from the mother to the fetus and to assist in the removal of waste products from the fetus to the mother
• the placenta therefore, provides a link between the maternal and fetal circulations while simultaneously acting as a barrier to protect the fetus from foreign substances m the maternal blood
• some embodiments of the methods and compositions described herein are for the modulation of access of drugs, calcineu ⁇ n inhibitors, chemicals and other substances through the placenta
• the methods and compositions involve the mo i ication o t e p acenta arrier to prevent t e entry o rugs t roug t e p acenta barrier and into the teta environment, e g , by efflux of
• Modulation of the placental barrier to prevent entry of drugs or other foreign substances to the fetal environment is important because of the sensitivity of the fetus to such substances.
• Studies have shown that nearly all drugs that are administered during pregnancy will enter, to some degree, the circulation of the fetus via passive diffusion, potentially harming the fetus during its growth and developmental stages See, e g , Syme, M R et al , Clin Pharmacokinet 43 487-514 (2004), herein incorporated by reference in its entirety
• the fetus may be additionally harmed by drugs that are actively pumped across the placenta by various transporters located on both the fetal and maternal side of the trophoblast layer
• Facilitated diffusion also appears to be a minor transfer mechanism for some drugs Modulation of the entry pathways through the placenta, therefore, is important to preventing fetal exposure to drugs and other substances present in the maternal circulation
• One of the functions of the placenta is to connect the fetus to the uterine wall near the fundus ute ⁇ , and more frequently on the posterior than on the ante ⁇ or wall of the uterus
• the placenta during fetal development is formed through the interweaving of both fetal and maternal portions, which allows the close proximity localization of the maternal and fetal circulation systems.
• the fetal portion of the placenta consists of the villi of the chorion frondosum These structures branch repeatedly, and increase in size throughout the fetal developmental stages
• the chorion frondosum villi are suspended in the intervillous space where they are bathed in maternal blood
• the circulation within the villi are conveyed to the space by the uterine arteries and earned away by the uterine veins
• a branch of an umbilical artery enters each villus and ends in a capillary plexus from which the blood is drained by a tributary of the umbilical vein
• the vessels of the villus are surrounded by a thin layer of mesoderm consisting of gelatinous connective tissue, which is covered by two strata of ectodermal cells derived from the trophoblast the deeper stratum
• the next layer of tissue consists of the mesodermic tissue, which represents the cytotrophoblast or layer of Langhans
• the maternal portion of the placenta is formed by the decidua placentalis containing the intervillous space As mentioned above, this space is produced by the enlargement and intercommunication of the spaces m the trophoblastic network
• the changes involve the disappearance of the greater portion of the stratum compactum, but the deeper part of this layer persists and is condensed to form what is known as the basal plate
• the stratum spongiosum and the boundary layer Through the stratum spongiosum, boundary layer and the basal plate, the uterine arteries and veins pass to and from the intervillous space
• the endothelial lining of the uterine vessels ceases at the point where they terminate in the intervillous space, which is lined by the syncytiotrophoblast
• Portions of the stratum compactum persist and are condensed to form a series of septa, which extend from the bas
• fetal and maternal blood currents traverse the placenta, the former passing through the blood vessels of the placental villi and the latter through the intervillous space
• the two circulations do not intermingle, being separated from each other by the delicate walls of the villi Nevertheless, the fetal blood is able to absorb, through the walls of the villi, oxygen and nutritive materials from the maternal blood, and give up to the latter its waste pro uc s.
• e pu ⁇ ie oo is carrie ac o e e us y e um i ica vein.
• e p acenta, tnereiore not on y establishes a mechanical connection between the mother and the fetus, but also provides nutrition, respiration, and excretion services for the fetus.
• the maternal blood does not communicate with the fetal circulation through the placenta.
• Maternal blood does not perfuse the placenta during the embryonic period and the feto-placental-maternal circulation does not become established until around the tenth week of pregnancy.
• access of drugs and other chemicals present in the maternal blood during the first 10 weeks of gestation occurs via diffusion through extracellular fluid.
• Maternal blood access to the placental circulation only occurs after development and establishment of the feto-placental-maternal circulation.
• Transplacental exchanges are known to involve passive transfer, active transport, facilitated diffusion, phagocytosis and pinocytosis. See, e.g., Pacifici GM, et al., Clin. Pharmacokinet. 28:235-69 (1995), herein incorporated by reference. Studies, however, have shown that phagocytotic and pinocytotic mechanisms are too slow to have any significant influence on drug or chemical transfer from the maternal circulation to the fetus. Syme et al. (2004). Therefore, one embodiment of the methods and compositions disclosed herein is to modulate passive transfer, facilitated diffusion and active transport of drugs, calcineurin inhibitors, chemicals and other substances across the placental barrier.
• Passive transfer represents the permeation of a molecule through a physical barrier, such as a cell membrane, down its concentration gradient. Passive diffusion does not require the input of energy, is not saturable and is not subject to competitive inhibition. When drugs cross the placenta by passive diffusion, the amount that crosses in any given time is dependent on the concentration of the drug in the maternal circulation, its physicochemical properties and the properties of the placenta that determine how readily the drug will pass. [0070] Passive diffusion is favored for low-molecular weight and highly lipid-soluble drugs that are predominantly un-ionized. The placenta resembles a lipid bilayer membrane, so only the non-protein bound portion of a drug, barring any applicable active-transport mechanisms, is free to diffuse across it.
• Another embodiment of the methods and compositions disclosed herein is the modulation of facilitated diffusion mechanisms in the placental barrier.
• Facilitated diffusion requires the presence of a carrier substance within the placenta.
• the transport of the system becomes saturated at high concentrations relative to the Michaelis-Menten constant (K m ) of the transporter.
• K m Michaelis-Menten constant
• Facilitated diffusion usually equalizes the concentration of drugs, chemicals, or substances between the maternal and fetal circulations. It may be that for many substances, such as carbohydrates, facilitated diffusion provides a means to increase transport rates when the functional and metabolic needs of the fetus would not be met by passive diffusion alone.
• Folkart GR et al. Am. J. Obstet. Gynecol., 80:221-223 (1960), herein incorporated by reference.
• Ganciclovir probably involves a combination of passive and facilitated diffusion mechanisms, the rate-limiting transfer step being passive diffusion.
• Another embodiment of the methods and compositions disclosed herein is use of modulators or calcineurin inhibitors in manipulating active transport of drugs, chemicals and other substances across the placental barrier.
• Active transport across the placental barrier requires energy, usually in the form of adenosine triphosphate (ATP) or through energy stored in the transmembrane electrochemical gradient provided by Na + , Cl " or H + . Because of the input of energy, active transport systems may work against a concentration gradient, however, saturation of the transporters can occur.
• ATP adenosine triphosphate
• Active drug transporters are located either in the maternal-facing brush border (apical) membrane or the fetal-facing basolateral (basal) membrane where they pump drugs into or out of the synctiotrophoblast.
• Table 2 summarizes the active transporters that have been identified in the placenta.
• P-Glycoproteins P-gP
• MDRl multidrug resistant gene
• P-glycoprotein is a member of the ATP-binding cassette (ABC) transporter family
• ABSC ATP-binding cassette
• P-gP is expressed in the trophoblast cells of the brush-border membrane, but not the basal membrane Cordon-Cardo C et al , J Histochem Cytochem 38-1277-87 (1990), Sugawara I, et al , Cancer Res 48 1926-1929 (1988), herein incorporated by reference in its entirety
• Studies have demonstrated that placental P-gP regulates the transfer of cyclospo ⁇ ne, vincristine, vinblastine and digoxm into trophoblast cells Ushigome F, et al , Eur J Pharmacol 408 1-10 (2000), Pavek P, et al., J Pharm Sci 10 1583- 1592 (2001), herein
• Toxicol 12 457-463 (1998), herein incorporated by reference) has shown that administration of an isomer of the pesticide avermectin was associated with a 100% incidence of fetal cleft palate in the mdrla knockout mice In contrast, heterozygous (+/-) mice were less sensitive and homozygous (+/+) mice insensitive at the same doses tested on the knockout mice In addition, the degree of chemical exposure was inversely related to the expression of P-gP, which was determined by fetal genotyping Other studies in mdrla knockout mice have confirmed the major fetoprotective role that the P-gP transporter plays Strut JW, et al , J Clin Invest 104 1441-1447 (1999)
• MRP Multidrug Resistance Associated Protein
• MRP 1 and MRP 3 were found to be localized primarily in the fetal endothelial cells of the placenta microcapillary Hipfner DR, et al , Biochim Biophys Acta 1461
• BCRP Breast Cancer Resistant Protein
• BCRP an ATP-d ⁇ ven transporter
• BCRP is highly expressed in the placenta Alhkmets R , et al , Cancer Res 58 5337-5339 (1998), herein incorporated by reference BCRP is responsible for rendering tumor cells resis an o c emoca cmeurm in i i ors, suc as opo ecan, mi oxantrone, oxoru icin ana aaunoruDicin.
• a en et al., Cancer Res. 59:4237-4241 (1999).
• BCRP has also been shown to restrict the passage of topotecan and mitoxantrone to the fetus in mice. Jonker JW et al , J. Natl. Cancer Inst. 92:1651-1656 (2000), herein incorporated by reference.
• Yet another embodiment is the modulation of monoamine transporters in placenta.
• SERT serotonin transporter
• NET norepinephrine transporter
• OCT3 extraneuronal monoamine transporter
• SERT and NET derive energy from the transmembrane Na + and Cl " electrochemical gradient, and are primarily localized in the brush-border membrane of the placental trophoblast. Both SERT and NET transport serotonin, dopamine and norepinephrine from the maternal circulation to the fetus. Drug substrates of the SERT and NET transporters include amphetamines, although cocaine and non-tricyclic antidepressants bind to the SERT and NET transporters with high affinity without being transferred across the membrane. [0082] OCT3 is localized to the basal membrane, where it transports serotonin, dopamine, norepinephrine and histamine via a Na + and Cl " independent system.
• Placental Na+-driven organic cation transporter 2 (OCTN2) has been identified and localized to the basal membrane of the synctiotrophoblast. Wu X et al., J. Pharmacol. Exp. Ther. 290:1482-1492 (1999), herein incorporated by reference. Placental OCTN2 transports carnitine across the placenta in the direction of the matemal-to-fetal transfer. Ohashi R., et al., J. Pharmacol. Exp. Ther. 291:778-784 (1999), herein incorporated by reference.
• MCT monocarboxylate
• NaDC3 dicarboxylate
• MCT monocarboxylate
• NaDC3 e.g. succinate transport
• Price NT et al , Biochem J. 329:321-328 (1998); Ganapathy V, et al., Biochem J. 249:179-184 (1988); Balkovetz DF, et al., 263:13823-13830 (1988), all incorporated by reference herein.
• Valproic acid a teratogenic substance, may be a substrate for MCT transfer, and compete with lactate for transport across the placental barrier.
• Transporter Modulators e.g., Activators or Inhibitors
• the invention provides compositions and methods for reducing or eliminating the effects of a calcmeu ⁇ n inhibitor in the CNS and/or in the fetus.
• the compositions and embodiments described herein . _ mo u a e e e ux o ca cineurin in i i or ou o p ysio ogica compar men s, inc u ing across tne Dioo ⁇ Dram barrier barrier via a BTB or fetal transport protein, e g , the P-gP transporter
• such modulators activate and/or increase the efflux by the BTB or fetal transport protein, e g , P-gP transporters on the blood brain barrier barriers
• Modulators may be any suitable modulator
• modulators useful in the invention are polyphenols, such as flavonoids
• Suitable modulators include catechins from green tea, including (-) epicatechin
• P-gP modulators for use herein include flavonols, including, but not limited to, kaempferol, quercetm, and galangin
• P-gP transporter modulators may include small molecules, including 2-p-Tolyl-
• a P-gP substrate is used to inhibit transport across the blood brain barrier and/or the placenta Multi Drug Resistance Proteins consist of a family of plasma membrane proteins encoded by the MDR
• the invention utilizes a modulator of a BTB transport protein
• the invention utilizes a modulator of a BTB transport protein that is an ABC transport protein
• the invention utilizes a BTB transport protein activator
• the BTB transport protein modulator is a modulator of P-gP, e g , an activator of P-gP
• compositions and methods of the invention are polyphenols
• Many polyphenols are modulators of BTB transport proteins, however, any suitable polyphenol that produces a decrease of one or more CNS effects of a calcineurin inhibitor, no matter what the mechanism, may be used in the compositions and methods of the invention
• a particularly useful class of polyphenols is the flavonoids Flavonoids, the most abundant polyphenols in the diet, can be classified into subgroups based on differences in their chemical structures The basic flavonoid structure is shown below (formula I)
• each R can be independently selected from the group consisting of hydrogen, substituted or unsubstituted hydroxyl, substituted or unsubstituted amine, substituted or unsubstituted thiol, substituted or unsubstituted C 1 -Ci 0 alkyl, substituted or unsubstituted C 1 -C 10 alkynyl, substituted or unsubstituted Ci-C 10 alkenyl, substituted or unsubstituted aryl, substituted or unsubstituted heteroaryl, substituted or unsubstituted C 5 -C 10 cycloalkyl, substituted or unsubstituted C 5 -C 10 heterocycloalkyl, substituted or unsubstituted C 1 -Ci 0 aliphatic acyl, substituted or unsubstituted Ci-Ci 0 aromatic acyl, trialkyl silyl, substituted or
• Carbohydrate as used herein, includes, but not limited to, monosaccharides, disaccharides, oligosaccharides, or polysaccharides.
• Monosaccharide for example includes, but not limited to, allose, altrose, mannose, gulose, Idose, glucose, galactose, talose, and fructose
• Disaccharides for example includes, but not limited to, glucorhamnose, trehalose, sucrose, lactose, maltose, galactosucrose, 7V-acetyllactosamine, cellobiose, gentiobiose, isomaltose, melibiose, p ⁇ meverose, hesperodmose, and rutinose
• Oligosaccharides for example includes, but not limited to, raffinose, nystose, panose, cellotriose, maltotriose, maltotetraose,
• the invention utilizes a flavonoid where the molecule is planar In some embodiments, the invention utilizes a flavonoid where the 2-3 bond is unsaturated In some embodiments, the invention utilizes a flavonoid where the 3- ⁇ osition is hydroxylated In some embodiments, the invention utilizes a flavonoid where the 2-3 bond is unsaturated and the 3-position is hydroxylated (e g , flavonols) [0094] In some embodiments, the invention utilizes one or more flavonoids selected from the group consisting of quercetin, isoquercetin, flavone, chrysin, apigenin, rhoifolin, diosmin, galangin, fisetm, mo ⁇ n, rutin, kaempferol, myricetm, taxifolm, naringenin, narmgin, hesperetin, hespe ⁇ dm, chalcone, ph
• the invention utilizes a flavonol
• the flavonol is selected from the group consisting of quercetin, fisetm, morin, rutin, myricetm, galangin, and kaempherol, and combinations thereof
• the flavonol is selected from the group consisting of quercetin, galangin, and kaempherol, and combinations thereof
• the flavonol is quercetin or a substituted analog thereof
• the flavonol is galangin
• the flavonol is kaempherol
• a particularly useful flavonol is quercetin Quercetin may be used to illustrate formulations and methods useful in the invention, however, it is understood that the discussion of quercetin applies equally to other flavonoids, flavonols, and polyphenols useful in the invention, e g , kaempferol and galangin [0097]
• quercetin Quercetin may be used to illustrate formulations and methods useful in the invention, however,
• quercetin also encompasses derivatives of quercetin, wherein each R can be independently selected from the group consisting of hydrogen, substituted or unsubstituted C 1 -C 10 alkyl, substituted or unsu stitute ary , su s i ute or unsu stitute 1 - 10 a ip atic acy , su s itu e or unsubstituted Ci-C 10 aromatic acyl, trialkyl silyl, substituted or unsubstituted ether, carbohydrate, and substituted carbohydrate, and its pharmaceutically acceptable salts, esters, prodrugs, analogs, isomers, stereoisomers or
• the quercetm is in a carbohydrate-derivatized form, e g , a quercetm-O-saccha ⁇ de
• a quercetm-O-saccha ⁇ de Quercetin-O-saccha ⁇ des useful in the invention include, but are not limited to, quercetm 3-O-glycoside, quercetm 3- O-glucorhamnoside, quercetm 3-O-galactoside, quercetm 3-O-xyloside, and quercetm 3-O-rhamnoside
• the invention utilizes a quercetm 7-O-saccharide
• the invention utilizes a quercetm aglycone
• a quercetm aglycone In some embodiments, a combination of aglycones and carbohydrate-de ⁇ vatized quercetins is used It will be appreciated that the various forms of quercetm may have different properties useful in the compositions and methods of the invention, and that the route of administration can determine the choice of forms, or combinations of forms, used in the composition or method Choice of a single form, or of combinations, is a matter of routine experimentation
• the invention features a composition or method utilizing quercetm to reduce or eliminate one or more side or fetal effects of a calcineurin inhibitor, such as tacrolimus or a tacrolimus analog
• a calcineurin inhibitor such as tacrolimus or a tacrolimus analog
• the quercetm is provided in a form for oral consumption
• Oral bioavailability of quercetm O-sacchandes is generally superior to that of quercetm aglycones
• the bioavailability of the various components is dependent on 1) the site of carbohydrate moiety or moieties and ⁇ ) the pendant sugar unit
• specific carriers are responsible for the absorption of various quercetm glycosides, as well as specific intestinal betaglucosidases After distribution in the body, the major metabolite, quercetm glucuronide (e g , quercetm 3-O-glucouronid), is found
• Oral bioavailability is sensitive to the presence of food factors
• the invention provides a composition for administration of quercetin to an animal , e g , for the oral delivery of quercetin to reduce a side effect of a calcmeurin inhibitor, that contain at least about 1 , 5, 10, 20, 30, 40, 50, 60, 70, 80, 90, 95, 99, 99 5, 99 9, or 99 99% quercetm-3-O-glycoside
• the invention provides a composition for the oral delivery of quercetin that contains no more than about 2, 5, 10, 20, 30, 40, 50, 60, 70, 80, 90, 95, 99, 99 5, 99 9,99 99, or 100% quercetin-3-O-glycoside
• the invention provides a composition that contains about 1-100% quercetin-3-O-glycoside, or about 10-100% quercetin- 3-O-glycoside, or about 20-100% quercetin-3-O-glycoside, or about 50-100% quercetm-3-O-glycoside
• the invention provides a composition that contains about 1-30% quercetin aglycone, or about 10-30% quercetin aglycone, or about 20-30% quercetin aglycone. In some embodiments, the invention provides a composition that contains about 1-20% quercetin aglycone, or about 10-20% quercetin aglycone. In some embodiments, the invention provides a composition that contains about 1-10% quercetin aglycone. In some embodiments, the invention provides a composition that contains about 1, 2, 5, 10, 20, 30, 40, 50, 60, 70, 80, 90, 95, 96, 97, 98, or 99% quercetin aglycone.
• the invention provides a composition for administration of quercetin to an animal, e.g., for the oral delivery of quercetin to reduce a side effect of a calcineurin inhibitor, that contains a combination of quercetin-O-saccharides.
• the invention provides a composition for administration of quercetin to an animal to reduce a side effect of a calcineurin inhibitor, e.g., for the oral delivery of quercetin, that contain a combination of quercetin-3-O-glycoside and quercetm-3-O-glucorhamnoside.
• the ranges or amounts of the quercetin-O-saccharides e.g., quercetin-3-O-glycoside and quercetin-3-O- glucorhamnoside maybe any suitable combination of the ranges or amounts, above.
• the invention provides a composition for administration of quercetin to an animal , e.g., for the oral delivery of quercetin to reduce a side effect of a calcineurin inhibitor, that contains a combination of one or more quercetin-O-saccharides and quercetin aglycone .
• the invention provides a composition for administration of quercetin to an animal to reduce a side effect of a calcineurin inhibitor, e.g., for the oral delivery of quercetin, that contain a combination of quercetin-3-O-glycoside and quercetin aglycone.
• the ranges or amounts of quercetin-3-O-glycoside and quercetin aglycone may be any suitable combination of the ranges or amounts, above.
• the invention provides a composition for administration of quercetin to an animal to reduce a side effect of a calcineurin inhibitor, e.g., for the oral delivery of quercetin, that contain a combination of quercetin-3-O- glucorhamnoside and quercetin aglycone.
• the ranges or amounts of quercetin-3-O- glucorhamnoside and quercetin aglycone may be any suitable combination of the ranges or amounts, above.
• the invention provides a composition for administration of quercetin to an animal to reduce a side effect of a calcineurin inhibitor, e.g., for the oral delivery of quercetin, that contain a combination of quercetin-3-O-glycoside, quercetin-3-O- glucorhamnoside and quercetin aglycone.
• a calcineurin inhibitor e.g., for the oral delivery of quercetin
• the ranges or amounts of quercetin-3-O-glycoside, quercetin-3-O- glucorhamnoside and quercetin aglycone may be any suitable combination of the ranges or amounts, above.
• Other quercetin saccharides, as described herein and as known in the art or developed, may be used as well.
• Quercetin may be modified to increase its solubility by derivatizing with at least one phosphate group.
• the phosphate group can be attached to any suitable part of the quercetin molecule.
• Quercetin may be modified to increase its solubility by attaching an amino acid such as glycine, alanine, dimethyl glycine, sarcosine, aspartic acid, or arginine.
• the amino acid can be attached to any suitable part of the quercetin molecule.
• a pharmaceutically acceptable excipient is also included.
• the invention provides compositions and methods, e.g., to reduce or eliminate side effects of a calcineurin inhibitor.
• the invention provides compositions and methods to reduce or eliminate side effects of a calcineurin inhibitor in the CNS and/or fetus.
• the compositions and methods retain or enhance a desired effect of the calcineurin inhibitor, e.g., a peripheral effect.
• the compos t ons an met o s c ange t e concentrat on o a ca c neur n n tor n a p ysiological compartment.
• T e methods and compositions of the invention apply to any calcineurin inhibitor for which it is desired to reduce one or more side effects, e.g., CNS and/or fetal effects.
• the compositions and methods of the invention utilize CsA.
• the compositions and methods of the invention utilize tacrolimus.
• the calcineurin inhibitor is tacrolimus analog.
• the tacrolimus analog is selected from the group consisting of meridamycin, 31-O-Demethyl-FK506; L-683,590, L-685,818; 32-O-(l- hydroxyethylindol-5-yl)ascomycin; ascomycin; C18-OH-ascomycin; 9-deoxo-31-O-demethyl-FK506; L-688,617; A-119435; AP1903; rapamycin; dexamethasone-FK506 heterodimer; 13-O-demethyl tacrolimus; and FK 506- dextran conjugate.
• Tacrolimus also known as FK506, is the active ingredient in Prograf, one of the leading market immunnosuppressants from preventing transplant rejection. Tacrolimus is a macrolide immunosuppressant that can be produced by Strep to myces tsukubaensis. It chemical name is [3S-[3R*[E(1S*,3S*,4S*)],
• tacrolimus 4, 10, 12, 18-tetramethyl-8-(2- ⁇ ropenyl)- 15,19-e ⁇ oxy-3H-pyrido[2, 1 -c] [ 1 ,4] oxaazacyclotricosine- 1 ,7,20,21 (4H,23H)- tetrone, monohydrate.
• the chemical structure of tacrolimus is:
• tacrolimus Its empirical formula is C 44 H 69 NO 12 -H 2 O (formula weight of 822.03).
• TCR T cell receptor
• CTL cytolytic T cells
• tacrolimus -based therapy offers a number of potential advantages over conventional CsA-based treatment, such as a corticosteroid-sparmg action and a significant reduction in incidence of both acute and cor
• Tacrolimus prolongs the survival of the host and transplanted graft in animal transplant models of liver, kidney, heart, bone marrow, small bowel and pancreas, lung and trachea, skin, cornea, and limb
• tacrolimus has been demonstrated to suppress some humoral immunity and, to a greater extent, cell-mediated reactions such as allograft rejection, delayed type hypersensitivity, collagen-mduced arthritis, experimental allergic encephalomyelitis, and graft versus host disease
• tacrolimus inhibits T lymphocyte activation, although the exact mechanism is unknown, experimental data suggest that upon formation of a complex with the intracellular protein, FK506-bmdrng protein 12 (FKBP 12), the drug selectively inhibits the enzymatic activity of the calcium/calmodulin- dependent protein phosphatase, calcineurin Engagement of the T cell receptor (TCR) initiates at least two separate signaling pathways driven by Ras/PKC and an elevation of intracellular Ca + The latter activates calcmeurm, composed of a catalytic subunit, a regulatory subunit and of calmodulin Enzymatically active calcmeurm can dephosphorylate the cytoplasmic NFAT family members and cause the dissociation of the inhibitor IkB from NFkB NFAT and NFkB are then translocated into the nucleus where they can interact with their DNA binding sequences on the IL-2 promoter To be transcriptionally active, NFAT needs to form a complex with accessory
• lymphokines such as interleukin-2, gamma interferon
• Calcineurin may also affect the function of the c-jun N-termmal kinase, JNK and of EIk-I, which are components of Ras/PKC d ⁇ ven signaling mechanisms The net result is that T lymphocyte activation is inhibited resulting in immunosuppression
• tacrolimus The greatest limitation to the therapeutic potential of tacrolimus comes from its toxic side effects, which include neurotoxicity, nephrotoxicity, diabetogemcity, and gastrointestinal disturbances
• the precise pathophysiological mechanisms of tacrolimus toxicity are still enigmatic, in part because the cells that are actually implicated within the target tissues of this toxicity have not been clearly identified
• the side effects of tacrolimus arise from the same biochemical mechanisms that underlie its immunosuppressive effects, namely an inhibition of calcmeu ⁇ n activity in various tissues
• the toxicity profile of tacrolimus overlaps with that of CsA and is totally different from that of rapamycin, an immunosuppressant that also binds FKBP 12 but unlike tacrolimus it does not inhibit calcmeurm
• FKBP12-binding analogs of tacrolimus that do not inhibit calcmeurm function are devoid of toxicity and the antagonist of FK506-induced immunosuppression, L-685,818,
• Tremor and headache have been associated with high whole-blood concentrations of tacrolimus and may respond to dosage adjustment. Seizures have occurred in adult and pediatric patients receiving Prograf. Coma and delirium also have been associated with high plasma concentrations of tacrolimus.
• Prografts The principal adverse reactions of Prograf are tremor, headache, diarrhea, hypertension, nausea, and abnormal renal function. These occur with oral and IV administration of Prograf and may respond to a reduction in dosing. Diarrhea was sometimes associated with other gastrointestinal complaints such as nausea and vomiting. Hyperkalemia and hypomagnesemia have occurred in patients receiving Prograf therapy. Hyperglycemia has been noted in many patients; some may require insulin therapy.
• the cyclosporine trough concentrations were above the pre-defined target range (i.e., 100-200 ng/mL) at Day 122 and beyond in 32-68% of the patients in the cyclosporine treatment arm, whereas the tacrolimus trough concentrations were within the pre-defined target range (i.e., 5-15 ng/mL) in 74-86% of the patients in the tacrolimus treatment arm. Only selected targeted treatment-emergent adverse events were collected in the US heart transplantation study.
• Those events that were reported at a rate of 15% or greater in patients treated with Prograf and mycophenolate mofetil include the following: any target adverse events (99.1%), hypertension (88.8%), hyperglycemia requiring antihyperglycemic therapy (70.1%), hypertriglyceridemia (65.4%), anemia (hemoglobin ⁇ 10.0 g/dL) (65.4%), fasting blood glucose >140 mg/dL (on two separate occasions) (60.7%), hypercholesterolemia (57.0%), hyperlipidemia (33.6%), WBCs ⁇ 3000 cells/mcL (33.6%), serious bacterial infections (29.9%), magnesium ⁇ 1.2 mEq/L (24.3%), platelet count ⁇ 75,000 cells/mcL (18.7%), and other opportunistic infections (15.0%).
• Other targeted treatment-emergent adverse events in Prograf-treated patients occurred at a rate of less than 15%, and include the following: Cushingoid features, impaired wound healing, hyperkalemia, Candida
• Anorexia, cholangitis, cholestatic jaundice, diarrhea, duodenitis, dyspepsia, dysphagia, esophagitis, flatulence, gastritis, gastroesophagitis, gastrointestinal hemorrhage, GGT increase, GI disorder, GI perforation, hepatitis, hepatitis granulomatous, ileus, increased appetite, jaundice, liver damage, liver function test abnormal, nausea, nausea and vomiting, oesophagitis ulcerative, oral moniliasis, pancreatic pseudocyst, rectal disorder, stomatitis, vomiting.
• Musculoskeletal [00133] Arthralgia, cramps, generalized spasm, joint disorder, leg cramps, myalgia, myasthenia, osteoporosis
• Atrial fibrillation atrial flutter, cardiac arrhythmia, cardiac arrest, electrocardiogram T wave abnormal, flushing, myocardial infarction, myocardial ischaemia, pericardial effusion, QT prolongation, Torsade de Pomtes, venous thrombosis deep limb, ventricular extrasystoles, ventricular fibrillation astrointestina
• Bile duct stenosis colitis, enterocolitis, gastroenteritis, gastrooesophageal reflux disease, hepatic cytolysis, hepatic necrosis, hepatotoxicity, impaired gastric emptying, liver fatty, mouth ulceration, pancreatitis haemorrhagic, pancreatitis necrotizing, stomach ulcer, venoocclusive liver disease
• Carpal tunnel syndrome cerebral infarction, hemrparesis, leukoencephalopathy, mental disorder, mutism, quad ⁇ plegia, speech disorder, syncope
• Urogenital Acute renal failure, cystitis haemorrhagic, hemolytic-uremic syndrome, micturition disorder
• Tacrolimus is a substrate of P-gP and is pumped out from the brain (Kochi et al Eur J Pharmacol 1999, 372 287, Yokogawa et al Pharm Res 1999, 16 1213)
• concentration of tacrolimus in the brain was markedly increased by depleting the mdrl gene in mice (Yokogawa et al Pharm Res 1999, 16 1213)
• tacrolimus induced neurotoxicity may occur as a result of the reduced P-gP function
• This report was based on the correlation of neurotoxic events of tacrolimus and ABCBl polymorphisms associated with expressions levels and function of P-gP (Yamaucm et al
• the invention provides compositions and methods utilizing an agent that reduces or eliminates a side effect associated with calcineu ⁇ n inhibitor treatment
• the invention also provides compositions and methods utilizing an agent that increases a therapeutic effect associated with calcineurin inhibitor treatment.
• the invention also provides compositions and methods utilizing an agent that changes the concentration in a physiological compartment of a calcineurin inhibitor.
• the invention provides compositions and methods utilizing a combination of a calcineurin inhibitor and an agent that reduces or eliminates a side effect associated with calcineurin inhibitor treatment
• the side effect-decreasing agent is a modulator of a blood brain barrier (BBB)
• BTB blood brain barrier
• BTB blood brain barrier
• the invention also provides compositions and methods utilizing an agent that reduces or eliminates fetal effect associated with calcineurin inhibitor treatment
• BBB transport protein modulator and "BTB transport protein modulator” are used interchangeably herein
• the methods and compositions are useful in the treatment of an animal in need of treatment, where it is desired that one or more effects of the calcineurin inhibitor or a developing fetus be reduced or eliminated
• the methods and compositions are useful in the treatment of an animal in need of treatment, where it is desired that one or more effects of the calcineurin inhibitor or a developing fetus be reduced or eliminated
• the methods and compositions are useful in the treatment of an
• a modulator of a BTB transport protein may be an activator or an inhibitor of the protein
• the modulatory effect may be dose-dependent, e g , some modulators act as activators m one dosage range and inhibitors in another
• a modulator of a BTB transport protein is used in a dosage wherein it acts primarily as an activator
• the use of the BTB or placental barrier transport protein modulator, e g , activator results in a decrease m one or more side and/or fetal effects of the calcineurin inhibitor
• the therapeutic effect(s) of the calcineu ⁇ n inhibitor may be decreased, remain the same, or increase, however, in preferred embodiments, if the therapeutic effect is decreased, it is not decreased to the same degree as the side or fetal effects It will be apprecia e a a given ca cineurin in i i or may ave more an one erapeu ic e ect and or one or more si e or fetal effects, and it is possible that the therapeutic ratio (in this case, the ratio of change in desired effect to change in undesired effect) may vary depending on which effect is measured However, at least one therapeutic effect of the calcineurin inhibitor is decreased to a lesser degree than at least one side effect of the calcmeurm inhibitor In some embodiments, the use of the BTB
• one or more therapeutic effects of the calcineurin inhibitor is enhanced by use in combination with a BTB transport protein modulator, while one or more side effects of the calcineu ⁇ n inhibitor is reduced or substantially eliminated
• the immunosuppressant effect of the calcineurin inhibitor is enhanced while one or more side effects of the calcmeurm inhibitor is reduced or substantially eliminated
• the concentration of the calcineurin inhibitor is changed in a physiological compartment by using the calcmeurm inhibitor in combination with a BTB transport protein modulator
• physiological compartments include, but are not limited to, blood, liver, lymph node, spleen, peyer's patches, mtestmes, lungs, heart, kidney, pancreas, and gull bladder
• the methods and compositions of the mvention operate by reducing or eliminating the concentration of the calcineurin inhibitor from the compartment where the side effect is produced (e g , brain) and/or fetal compartment, while retaining or even increasing the effective concentration of the calcineurin inhibitor in the periphery and/or compartment where the therapeutic effect is desired
• Calcmeurm inhibitor act at least m part by peripheral mechanisms (e g inhibition of T lymphocyte activation) and may thus retain some or all of their activity, or even display enhanced therapeutic activity, while at the same time side and/or fetal effects are reduced or eliminated
• the BTB transport protein modulator decreases the clearance of the calcineurin inhibitor from the compartment where the calcineurin inhibitor is exerting its therapeutic effect
• the methods and compositions of the invention operate by reducmg or eliminating the concentration
• compositions that include a calcmeurm inhibitor and a Blood-Tissue barrier (BTB) transport
• compositions of the invention include one or more calcmeurm inhibitor with one or more calcmeurm inhibitor as well as one or more than one BTB transport protein modulator
• One or more of the calcineurin inhibitors may have one or more side effects which are desired to be decreased
• the dosage of the BTB transport modulator may be adjusted such that the side effect of the calcineurin inhibitor are reduced without a substantial reduction of the therapeutic effect in the target cells
• compositions of the invention may be prepared in any suitable form for administration to an animal In some embodiments, the invention provides pharmaceutical compositions
• compositions suitable for oral administration are suitable for transdermal administration
• compositions are suitable for injection by any standard route of injection, e g , intravenous, subcutaneous, intramuscular, or intraperitoneal Compositions suitable for other routes of administration are also encompassed by the invention, as described herein
• BTB transport protein modulators of use in the invention include any suitable BTB transport modulators In some embodiments, the BTB transport protein modulator is one or more polyphenols In some embodiments, the BTB transport protein modulator is one or more flavonoids In some embodiments, the BTB transport protein modulator is quercetin
• the invention provides methods of treatment
• the invention provides a method of treating a condition by administering to an animal suffering from the condition an effective amount of a calcineurin inhibitor and an amount of a BTB transport protein modulator, e g , activator, sufficient to reduce or eliminate a side effect of the calcineurin inhibitor
• the BTB transport protem modulator is a BTB transport protein activator
• the calcineurin inhibitor is tacrolimus or a .
• the invention provides methods for treatment of organ transplant
• Example or organ transplant include but are not limited to kidney transplant, pancreas transplant, liver transplant, heart transplant, lung transplant, intestine transplant, pancreas after kidney transplant, and simultaneous pancreas-kidney transplant
• the invention provides methods for the treatment of an autoimmune disease
• autoimmune diseases include, but are not limited to, Rheumatoid Arthritis, Lupus nephritis, actopic dermatiti
• the invention provides methods of decreasing a side effect of a calcineurin inhibitor in an animal, e g a human, that has received an amount of the calcineu ⁇ n inhibitor sufficient to produce a side effect by administering to the animal, e g , human, an amount of a BTB transport protein modulator sufficient to reduce or eliminate the side effect
• the methods and compositions of the present invention can be used to modulate transport of a variety of calcineurin inhibitors
• the dosage of the calcineurin inhibitor will be modulated according to the effect of the transport protein modulator For instance, less calcmeurm inhibitor may be needed to reach optimal effect when co-administered with the transport protein modulator
• co-administermg the transport protem modulator with a calcmeurm inhibitor will allow for chronically administering the drug without drug escalation and/or without dependence on the drug
• coadministering the transport protein modulator will allow for the elimination of a calcineurin inhibitor from a physiological compartment, e g wash out drug from central nervous system to reduce CNS effects
• the physiological compartment is a central nervous system
• the physiological compartment is a renal system
• the physiological compartment is a pancreatic system
• the physiological compartment is a hepatic
• the invention provides methods of decreasing a CNS, reproductive, gastrointestinal, pancreatic, renal and or hepatic effect of a calcineurin inhibitor in an animal, e g a human, that has received an amount of the calcineurin inhibitor sufficient to produce a side effect by administering to the animal, e g , human, an amount of a BTB transport protein modulator sufficient to reduce or eliminate the side effect
• side effect encompasses any effect of a substance, e g a CNS, pancreatic, renal and or hepatic effect
• the effect may be acute or chronic
• the effect may be biochemical, cellular, at the tissue level, at the organ level, at the multi-organ level, or at the level of the entire organism
• the effect may manifest in one or more objective or subjective manners, any of which may be used to measure the effect
• the effect may be a pathological effect
• the CNS effect of a substance can be tremors, headache, changes in motor function, changes in mental status, changes in sensory functions, seizures, insomnia, paresthesia, dizziness, coma or delirium, as well as other effects mention herein, or combinations thereof
• the renal and/or urogenital side effect is selected from the group consisting of nephrotoxicity, renal function impairment, creatinine increase, urinary tract infection, oliguria, cystitis haemorrhagic, hemolytic -uremic syndrome or micturition disorder, as well as o er e ec s men ion erein, or com ina ions ereo n some em o imen s, e epatic, pancreatic an ⁇ or gastrointestinal side effect is selected from the group consisting of hepatic necrosis, hepatotoxicity, liver fatty, venooclusive liver disease, diarrhea, nausea, constipation, vomiting,
• methods and compositions of the invention decrease the effect of a calcmeu ⁇ n inhibitor on tissue metabolic function of an animal, e g a human, that has received an amount of the calcineurin inhibitor sufficient to produce a decrease in tissue metabolic function, the decrease in the effect of the calcineurin inhibitor is accomplished, for example, by administering to the animal, e g , human, an amount of a BTB transport protein modulator sufficient to reduce or eliminate the decrease in tissue metabolic function.
• tissue metabolic function includes the biochemical reactions that allow the tissue to perform its normal function such as anabolism, catabohsm, movement, accumulation of molecules and the like [00175]
• co-admiwel ⁇ ng the transport protein modulator will allow for a change in concentration of a calcineurin inhibitor in a physiological compartment, e g increase of calcineurin inhibitor in the periphery
• an effect is measured objectively or subjectively (e g , drowsiness, tremor, and the like)
• any suitable method for evaluation of objective or subjective effect may be used Examples include visual and numeric scales and the like for evaluation by an individual
• a further example includes sleep latency for measurement of drowsiness, or standard tests for measurement of concentration, mentation, memory, and the like
• fetal effect encompasses any effect encompasses any effect of a substance that is introduced into the maternal system on the fetus
• the effect may be acute or chronic
• the effect may be biochemical, cellular, at the tissue level, at the organ level, at the multi-organ level, or at the level of the entire organism
• therapeutic benefit is meant eradication or amelioration of the underlying disorder being treated
• a therapeutic benefit is achieved with the eradication or amelioration of one or more of the physiological symptoms associated with the underlying disorder such that an improvement is observed in the patient, notwithstanding that the patient may still be afflicted with the underlying disorder
• the compositions may be administered to a patient at risk of developing a particular disease, or to a patient reporting one or more of the physiological symptoms of a disease, even though a diagnosis of this disease may not have been made
• a prophylactic effect includes delaying or eliminating the appearance of a disease or condition, delaying or eliminating the onset of symptoms of a disease or condition, slowing, halting, or reversing the progression of a disease or condition, or any combination thereof
• physiological compartment includes physiological structures, such as organs or organ groups or the fetal compartment, or spaces whereby a physiological or chemical barrier exists to exclude compounds or agents from the internal or external portion of the physiological structure or space
• physiological compartments include the central nervous system, blood and other bodily fluids, the fetal compartment and internal structures contained within organs, such as the ovaries and testes omposi ions
• compositions that include an agent, e g , that reduces or eliminates a side and/or fetal effect of one or more calcineurin inhibitors
• the calcmeurin inhibitor is coadministered with the agent that reduces the side effect "Co-administration," "administered in combination with,” and their grammatical equivalents, as used herein, encompasses administration of two or more agents to an animal so that both agents and/or their metabolites are present in the animal at the same time
• Co-administration includes simultaneous administration in separate compositions, administration at different times in separate compositions, or administration in a composition m which both agents are present
• the invention provides compositions containing a combination of a calcineurin inhibitor and an agent, e g , that reduces or eliminates side and/or fetal effect of the calcineurin inhibitor
• the invention provides compositions containing a combination of a calcineurin inhibitor and an agent that changes the concentration in a physiological compartment of the calcineurin inhibitor
• the invention provides pharmaceutical compositions that further include a pharmaceutically acceptable excipient
• the pharmaceutical compositions are suitable for oral administration
• the pharmaceutical compositions are suitable for transdermal administration
• the pharmaceutical compositions are suitable for injection Other forms of administration are also compatible with embodiments of the pharmaceutical compositions of the invention, as described herein
• the BTB transport protein is an ABC transport protein In some embodiments, the BTB transport protein modulator is a BTB transport protein activator In some embodiments, the BTB transport protein modulator is a BTB transport protein inhibitor In some embodiments, the BTB transport protein modulator is a modulator of P-gP
• the BTB transport protein modulator comprises a polyphenol
• a polyphenol which acts to lower a side effect of a calcineurin inhibitor through a non-BTB transport protein-mediated mechanism, or that acts to lower a side effect of a calcineurin inhibitor through a BTB transport protein-mediated mechanism and a non-BTB transport protein-mediated mechanism is used
• a polyphenol which acts to increase a therapeutic effect of a calcineurin inhibitor through a non-BTB transport protein-mediated mechanism, or that acts to increase a therapeutic effect of a calcineurin inhibitor through a BTB transport protem-mediated mechanism and a non-BTB transport protem-mediated mechanism is used
• the side effect of the calcineurin inhibitor that is reduced is selected from the group consisting of CNS side effects, renal and/or urogenital side effects, reproductive system side effects, pancreatic, hepatic and/or gastrointestinal side effects, and combinations thereof n some em o iments, t e e ect o t e ca cineu ⁇ n in i itor t at is re uced is selecte irom the group consisting of headache, tremor, lmsonia, paresthesia, dizziness, abnormal dreams, agitation, amnesia, anxiety, confusion, convulsion, crying, depression, elevated mood, emotional lability, encephalopathy, haemorrhagic stroke, hallucinations, hypertonia, incoordination, monoparesis, myoclonus, nerve compression, nervousness, neuralgia, neuropathy, paralysis flaccid, psychomotor skills impaired, psychosis, quadnparesis
• the CNS effect of the calcineurin inhibitor that is reduced is selected from the group consisting of headache, tremor, lmsonia, paresthesia, dizziness
• the CNS effect of the calcineurin inhibitor that is reduced is tremor
• the CNS effect of the calcineurin inhibitor that is reduced is headache
• the CNS effect of the calcineu ⁇ n inhibitor that is reduced is imsonia
• the CNS effect of the calcineurin inhibitor that is reduced is paresthesia
• the CNS effect of the calcineurin inhibitor that is reduced is dizziness
• the renal and/or urogenital side effect is selected from the group consisting of nephrotoxicity, renal function impairment, creatinine increase, urinary tract infection, oliguria, cystitis haemorrhagic, hemolytic -uremic syndrome or micturition disorder, as well as other effects mention herein, or combinations thereof
• the hepatic, pancreatic and/or gastrointestinal side effect is selected from the group consisting of hepatic necrosis, hepatotoxicity, liver fatty, venooclusive liver disease, diarrhea, nausea, constipation, vomiting, dyspepsia, anorexia, or LFT abnormal, as well as other effects mention herein, or combinations thereof [00188]
• the side effect is a decrease in tissue metabolic function
• the calcineurin inhibitor is CsA In some embodiments the calcineurin inhibitor is tacrolimus In some embodiments, the calcineurin inhibitor is tacrolimus analog In some embodiments, the tacrolimus analog is selected from the group consisting of me ⁇ damycin, 31-O-Demethyl-FK506, L-683,590, L- 685,818, 32-O-(l-hydroxyethyhndol-5-yl)ascomycin, ascomycin, C18-OH-ascomycm, 9-deoxo-31-O-demethyl- FK506, L-688,617, A-119435, AP1903, rapamycin, dexamethasone-FK506 heterodimer, 13-O-demethyl tacrolimus, and FK 506-dextran conjugate
• the invention provides a composition containing a calcineurin inhibitor and a Blood- Tissue barrier (BTB) transport protein modulator, where the calcineurin inhibitor is present in an amount sufficient to exert a therapeutic effect and the BTB transport protein modulator is present in an amount sufficient to decrease a side effect of the calcineu ⁇ n inhibitor by a measurable amount, compared to the side effect without the BTB transport protein modulator, when the composition is administered to an animal
• a side effect of the calcineurin inhibitor is decreased by an average of at least about 5, 10, 15, 20, 25, 30, 35, 40, 45, 50, 55, 60, 65, 70, 75, 80, 85, 90, 95, or more than 95%, compared to the side effect without the BTB transport protein modulator
• a side effect of the calcineurin inhibitor is decreased by an average of at least about 5%, compared to the side effect without the BTB transport protein modulator
• a side effect of the calcineurin inhibitor is decreased by an average of at least about 5%,
• the invention provides compositions that contain a polyphenol, e g , a flavonol, and a calcmeu ⁇ n inhibitor, where the calcmeurm inhibitor is present m an amount sufficient to exert an therapeutic effect and the polyphenol, e g , a flavonol is present in an amount sufficient to decrease side effect of the calcineu ⁇ n inhibitor by a measurable amount, compared to the side effect without the polyphenol, e g , a flavonol when the composition is administered to an animal
• the measurable amount may be an average of at least about 5%, 10%, 15%, 20%, or more than 20% as described herein
• the side effect may be any side effect as desc ⁇ bed herein
• the side effect of the calcmeunn inhibitor that is reduced is selected from the group consisting of CNS side effects, renal and/or urogenital side effects, reproductive system side effects, pancreatic, hepatic and/or gastrointestinal side effects, and combinations thereof.
• the invention provides compositions that contain a flavonol that is quercetin, isoquercetin, flavon, chrysm, apigenm, rhoifolm, diosmin, galangm, fisetin, mo ⁇ n, rutin, kaempferol, myricetin, taxifolm, narmgenm, na ⁇ ngm, hesperetin, hespe ⁇ din, chalcone, phloretin, phlorizdin, geddlingm, biochanm A, catechm, or epicatechm, or a combination thereof, and a calcmeurm inhibitor that is tacrolimus, where the tacrolimus is present in an amount sufficient to exert a therapeutic effect and the flavonol is present in an amount sufficient to decrease a side effect of tacrolimus by a measurable amount, compared to the side effect without the flavonol when the composition is administered to an animal
• the hepatic, pancreatic and/or gastrointestinal side effect is selected from the group consisting of hepatic necrosis, hepatotoxicity, liver fatty, venooclusive liver disease, diarrhea, nausea, constipation, vomiting, dyspepsia, anorexia, or LFT abnormal, as well as other effects mention herein, or combinations thereof.
• the side effect is a decrease in tissue metabolic function.
• the invention provides compositions that contain a flavonol that is quercetin, galangin, or kaempferol, or combination thereof, and a calcineurin inhibitor that is tacrolimus, where tacrolimus is present in an amount sufficient to exert a therapeutic effect and the flavonol is present in an amount sufficient to decrease a side effect of tacrolimus by a measurable amount, compared to the side effect without the flavonol when the composition is administered to an animal.
• the measurable amount may be an average of at least about 5%, 10%, 15%, 20%, or more than 20% as described herein.
• the side effect may be any side effect as described herein.
• the side effect of the calcineurin inhibitor that is reduced is selected from the group consisting of CNS side effects, renal and/or urogenital side effects, reproductive system side effects, pancreatic, hepatic and/or gastrointestinal side effects, and combinations thereof.
• the side effect of the calcineurin inhibitor that is reduced is a CNS side effect.
• the CNS effect of the calcineurin inhibitor that is reduced is selected from the group consisting of headache, tremor, imsonia, paresthesia, dizziness.
• the CNS effect is tremor.
• the CNS effect is headache.
• the CNS effect is insomnia.
• the CNS effect is paresthesia.
• the renal and/or urogenital side effect is selected from the group consisting of nepnrotoxicity, renal function impairment, creatinine increase, urinary tract infection, oliguria, cystitis haemorrhagic, hemolytic-uremic syndrome or micturition disorder, as well as other effects mention herein, or combinations thereof.
• the hepatic, pancreatic and/or gastrointestinal side effect is selected from the group consisting of hepatic necrosis, hepatotoxicity, liver fatty, venooclusive liver disease, diarrhea, nausea, constipation, vomiting, dyspepsia, anorexia, or LFT abnormal, as well as other effects mention herein, or combinations thereof.
• the side effect is a decrease in tissue metabolic function.
• the invention provides compositions that contains quercetin and tacrolimus where the tacrolimus is present in an amount sufficient to exert a therapeutic effect and the quercetin is present in an amount sufficient to decrease a side effect of tacrolimus by a measurable amount, compared to the side effect without the quercetin when the composition is administered to an animal.
• the measurable amount may be an average of at least about 5%, 10%, 15%, 20%, or more than 20% as described herein.
• the side effect may be any side effect as described herein.
• the side effect of the calcineurin inhibitor that is reduced is selected from the group consisting of CNS side effects, renal and/or urogenital side effects, reproductive system side effects, pancreatic, hepatic and/or gastrointestinal side effects, and combinations thereof.
• the side effect of the calcineurin inhibitor that is reduced is a CNS side effect.
• the CNS effect of the calcineurin inhibitor that is reduced is selected from the group consisting of headache, tremor, imsonia, paresthesia, dizziness.
• the CNS effect is tremor.
• the CNS effect is headache.
• the CNS effect is insomnia.
• the CNS effect is paresthesia.
• the renal and/or urogenital side effect is selected from the group consisting of nepnrotoxicity, renal function impairment, creatinine increase, urinary tract infection, oliguria, cystitis haemorrhagic, hemolytic- uremic syndrome or micturition disorder, as well as other effects mention herein, or combinations thereof.
• nepnrotoxicity nepnrotoxicity
• renal function impairment nepnrotoxicity
• creatinine increase urinary tract infection
• oliguria cystitis haemorrhagic
• hemolytic- uremic syndrome or micturition disorder as well as other effects mention herein, or combinations thereof.
• the side effect is a decrease in tissue metabolic function
• the invention provides a composition containing a calcineurm inhibitor and a Blood- Tissue barrier (BTB) transport protein modulator, where the calcmeu ⁇ n inhibitor is present m an amount sufficient to exert a therapeutic effect and the BTB transport protein modulator is present in an amount sufficient to increase a therapeutic effect of the calcineurm inhibitor by a measurable amount, compared to the therapeutic effect without the BTB transport protein modulator, when the composition is administered to an animal
• a therapeutic effect of the calcineurm inhibitor is increased by an average of at least about 5, 10, 15, 20, 25, 30, 35, 40, 45, 50, 55, 60, 65, 70, 75, 80, 85, 90, 95, or more than 95%, compared to the therapeutic effect without the BTB transport protein modulator
• a therapeutic effect of the calcineu ⁇ n inhibitor is increased by an average of at least about 5%, compared to the therapeutic effect without the BTB transport protein modulator
• the invention provides compositions that contain a flavonol that is quercetm, isoquercetin, flavon, chrysin, apigemn, rhoifolm, diosmin, galangm, fisetin, mo ⁇ n, rutin, kaempferol, myricetin, taxifolm, narmgenm, na ⁇ ngm, hesperetm, hesperidin, chalcone, phloretin, phlo ⁇ zdin, geddlingm, biochanin A, catechin, or epicatechin, or a combination thereof, and a calcineurm inhibitor that is tacrolimus, where the tacrolimus is present in an amount sufficient to exert a therapeutic effect and the flavonol is present in an amount sufficient to increase a therapeutic effect of tacrolimus by a measurable amount, compared to the therapeutic effect without the flavonol when the composition is administered to an animal
• the invention provides compositions that contain a flavonol that is quercetm, galangin, or kaempferol, or combination thereof, and a calcineurm inhibitor that is tacrolimus, where tacrolimus is present in an amount sufficient to exert a therapeutic effect and the flavonol is present in an amount sufficient to increase a therapeutic effect of tacrolimus by a measurable amount, compared to the therapeutic effect without the flavonol when the composition is administered to an animal
• the measurable amount may be an average of at least about 5%, 10%, 15%, 20%, or more than 20% as desc ⁇ bed herein n some em o imen s, e inven ion provi es composi ions a con ains quercetin and tacrolimus w ere the tacrolimus is present in an amount sufficient to exert a therapeutic effect and the quercetin is present m an amount sufficient to increase a therapeutic effect of tacrolimus by a measurable
• the BTB transport protein modulator is present in an amount sufficient to decrease a side effect of the calcineurin inhibitor by a measurable amount and to increase a therapeutic effect of the calcineu ⁇ n inhibitor by a measurable amount, compared to the side effect and therapeutic effect without the BTB transport protein modulator, when the composition is administered to an animal
• a therapeutic effect of the calcineurin inhibitor is increased by an average of at least about 5, 10, 15, 20, 25, 30, 35, 40, 45, 50, 55, 60, 65, 70, 75, 80, 85, 90, 95, or more than 95%, compared to the therapeutic effect without the BTB transport protein modulator
• a therapeutic effect of the calcineurin inhibitor is increased by an average of at least about 5%, compared to the therapeutic effect without the BTB transport protein modulator.
• a therapeutic effect of the calcineu ⁇ n inhibitor is increased by an average of at least about 10%, compared to the therapeutic effect without the BTB transport protein modulator In some embodiments, a therapeutic effect of the calcineurin inhibitor is increased by an average of at least about 15%, compared to the therapeutic effect without the BTB transport protein modulator In some embodiments, a therapeutic effect of the calcineurin inhibitor is increased by an average of at least about 20%, compared to the therapeutic effect without the BTB transport protein modulator In some embodiments, a therapeutic effect of the calcineurin inhibitor is increased by an average of at least about 30%, compared to the therapeutic effect without the BTB transport protein modulator In some embodiments, a therapeutic effect of the calcineurin inhibitor is increased by an average of at least about 40%, compared to the therapeutic effect without the BTB transport protein modulator In some embodiments, a therapeutic effect of the calcineurin inhibitor is increased by an average of at least about 50%, compared to the therapeutic effect without the BTB transport protein modulator
• the invention provides compositions containing a BTB transport protein modulator present in an amount sufficient to decrease a side effect of a calcineu ⁇ n inhibitor by an average of at least about 5% and to increase a therapeutic effect of the calcineurin inhibitor by an average of at least about 5%, compared to the side effect and therapeutic effect without the BTB transport protein modulator, when the composition is administered to an animal in combination with the calcineurin inhibitor.
• the invention provides compositions containing a BTB transport protein modulator present in an amount sufficient to decrease a side effect of a calcineurin inhibitor by an average of at least about 10% and to increase a therapeutic effect of the calcineurin inhibitor by an average of at least about 10%, compared to the side effect and therapeutic effect without the BTB transport protein modulator, when the composition is administered to an animal in combination with the calcineurin inhibitor
• the invention provides compositions containing a BTB transport protein modulator present m an amount sufficient to decrease
• the invention provides compositions containing a BTB transport protein modulator present in an amount sufficient to decrease a side effect of a calcineurin inhibitor by an average of at least about 10% and to increase a therapeutic effect of the calcineurin inhibitor by an average of at least about 20%, compared to the side effect and therapeutic effect without the BTB transport protein modulator, when the composition is administered to an anima in com ina ion wi t e ca cineurm in i i or n some em o imen s, e invention provides compositions containing a BTB transport protein modulator present in an amount sufficient to decrease a side effect of a calcineurm inhibitor by an average of at least about 10% and to increase a therapeutic effect of the calcmeu ⁇ n inhibitor by an average of at least about 30%, compared to the side effect and therapeutic effect without the BTB transport protein modulator, when the composition is administered to an animal in combination with the calcineu ⁇ n inhibitor
• the invention provides compositions containing a BTB transport protein modulator
• the mvention provides compositions containing a polyphenol, e g , a flavonol such as quercetin, present in an amount sufficient to decrease a side effect of a calcmeu ⁇ n inhibitor by an average of at least about 5% and to increase a therapeutic effect of the calcineurm inhibitor by an average of at least about 5%, when the composition is administered to an animal in combination with the calcmeurin inhibitor, compared to the side effect and therapeutic effect without the polyphenol, e g , flavonol such as quercetin
• the invention provides compositions containing a polyphenol, e g , a flavonol such as quercetin present in an amount sufficient to decrease a side effect of a calcmeurin inhibitor by an average of at least about 10% and to mcrease a therapeutic effect of the calcineurm inhibitor by an average of at least about 10%, when the composition is administered to an animal in combination with the calcmeurin inhibitor,
• the invention provides compositions containing a polyphenol, e.g., a flavonol such as quercetin present in an amount sufficient to decrease a side effect of a calcineurin inhibitor by an average of at least about 10% and to increase a therapeutic effect of the calcineurin inhibitor by an average of at least about 50%, when the composition is administered to an animal in combination with the calcineurin inhibitor, compared to the side effect and therapeutic effect when the calcineurin inhibitor is administered without the a polyphenol, e.g., a flavonol such as quercetin.
• a polyphenol e.g., a flavonol such as quercetin
• the invention provides a composition that contains a polyphenol that is quercetin, isoquercetin, flavon, chrysin, apigenin, rhoifolin, diosmin, galangin, fisetin, morin, rutin, kaempferol, myricetin, taxifolin, naringenin, naringin, hesperetin, hesperidin, chalcone, phloretin, phlorizdin, genistein, biochanin A, catechin, or epicatechin, or combinations thereof, and a calcineurin inhibitor, such as tacrolimus or a tacrolimus analog, where the calcineurin inhibitor is present in an amount sufficient to exert a therapeutic effect, and the polyphenol is present in an amount effective to decrease a side effect of the calcineurin inhibitor by a measurable amount (e.g., an average of at least about 5, 10, 15, 20, or
• the side effect may be any side effect as described herein.
• the side effect of the calcineurin inhibitor that is reduced is selected from the group consisting of CNS side effects, renal and/or urogenital side effects, reproductive system side effects, pancreatic, hepatic and/or gastrointestinal side effects, and combinations thereof.
• the side effect of the calcineurin inhibitor that is reduced is a CNS side effect.
• the CNS effect of the calcineurin inhibitor that is reduced is selected from the group consisting of headache, tremor, imsonia, paresthesia, dizziness.
• the CNS effect is tremor.
• the CNS effect is headache.
• the CNS effect is insomnia.
• the CNS effect is paresthesia.
• the renal and/or urogenital side effect is selected from the group consisting of nephrotoxicity, renal function impairment, creatinine increase, urinary tract infection, oliguria, cystitis haemorrhagic, hemolytic-uremic syndrome or micturition disorder, as well as other effects mention herein, or combinations thereof.
• the hepatic, pancreatic and/or gastrointestinal side effect is selected from the group consisting of hepatic necrosis, hepatotoxicity, liver fatty, venooclusive liver disease, diarrhea, nausea, constipation, v ⁇ rS ⁇ ting, dyspepsia, anorexia, or LFT abnormal, as well as other effects mention herein, or combinations thereof.
• the side effect is a decrease in tissue metabolic function.
• the invention provides a composition that contains quercetin and tacrolimus, where tacrolimus is present in an amount sufficient to exert a therapeutic effect, and the quercetin is present in an amount effective to decrease a side effect of tacrolimus by a measurable amount (e.g., an average of at least about 5, 10, 15, 20, or more than 20%, as described herein) and to increase the therapeutic effect of tacrolimus by a measurable amount (e.g., an average of at least about 5, 10, 15, 20, or more than 20%, as described herein).
• the side effect may be any side effect as described herein.
• the side effect of the calcineurin inhibitor that is reduced is selected from the group consisting of CNS side effects, renal and/or urogenital side effects, reproductive system side effects, pancreatic, hepatic and/or gastrointestinal side effects, and combinations thereof. In some embodiments, the side effect of the calcineurin inhibitor that is reduced is a CNS side effect.
• the CNS effect of the calcineurin inhibitor that is reduced is selected from the group consisting o ea ac e, remor, lmsonia, pares esia, izziness n some em o imen s, ,e eiiect is tremor m some embodiments, the CNS effect is headache In some embodiments, the CNS effect is insomnia In some embodiments, the CNS effect is paresthesia In some embodiments, the renal and/or urogenital side effect is selected from the group consisting of nephrotoxicity, renal function impairment, creatinine increase, urinary tract infection, oliguria, cystitis haemorrhagic, hemolytic-uremic syndrome or micturition disorder, as well as other effects mention herein, or combinations thereof In some embodiments, the hepatic, pancreatic and/or gastrointestinal side effect is selected from the group consisting of hepatic necrosis, hepatotoxicity, liver fatty,
• the invention provides a composition containing an calcmeurin inhibitor and a Blood-Tissue barrier (BTB) transport protein modulator, where the calcmeurin inhibitor is present in an amount sufficient to exert a therapeutic effect and the BTB transport protein modulator is present in an amount sufficient to change the concentration m a physiological compartment of the calcmeurin inhibitor by a measurable amount, compared to the concentration of the calcmeurin inhibitor in the physiological compartment without the BTB transport protein modulator, when the composition is administered to an animal
• the BTB transport protein modulator decreases the concentration of a calcmeu ⁇ n inhibitor in a physiological compartment where a side effect is produced
• the concentration of the calcmeurin inhibitor is decreased by an average of at least about 5, 10, 15, 20, 25, 30, 35, 40, 45, 50, 55, 60, 65, 70, 75, 80, 85, 90, 95, or more than 95%, compared to the concentration without the BTB transport protein modulator
• the invention provides compositions that contain a polyphenol, e g , a flavonol, and an calcmeurin inhibitor, where the calcmeurin inhibitor is present m an amount sufficient to exert an therapeutic effect and the polyphenol, e g , a flavonol is present in an amount sufficient to decrease the concentration of the calcmeurin inhibitor in a physiological compartment by a measurable amount, compared to the concentration without the polyphenol, e g , a flavonol when the composition is administered to an animal
• the measurable amount may be an average of at least about 5%, 10%, 15%, 20%, or more than 20% as described herein
• the physiological compartment is a central nervous system
• the physiological compartment is a renal system
• the physiological compartment is a pancreatic system
• the physiological compartment is a hepatic system
• the physiological compartment is a fetal compartment , i n vono a is
• the measurable amount may be an average of at least about 5%, 10%, 15%, 20%, or more than 20% as described herein.
• the physiological compartment is a central nervous system.
• the physiological compartment is a renal system.
• the physiological compartment is a pancreatic system.
• the physiological compartment is a hepatic system In some embodiments, the physiological compartment is a fetal compartment.
• the invention provides compositions that contain a flavonol that is quercetin, galangm, or kaempferol, or combination thereof, and an calcmeu ⁇ n inhibitor that is tacrolimus, where tacrolimus is present in an amount sufficient to exert a therapeutic effect and the flavonol is present in an amount sufficient to decrease the concentration of tacrolimus by a measurable amount, compared to the concentration without the flavonol when the composition is administered to an animal
• the measurable amount may be an average of at least about 5%, 10%, 15%, 20%, or more than 20% as described herein
• the physiological compartment is a central nervous system
• the physiological compartment is a renal system
• the physiological compartment is a pancreatic system
• the physiological compartment is a hepatic system
• the physiological compartment is a fetal compartment
• the invention provides compositions that contain quercetin and tacrolimus where tacrolimus is present in an amount sufficient to exert a therapeutic effect and the quercetin is present in an amount sufficient to decrease the concentration of tacrolimus in a physiological compartment by a measurable amount, compared to the concentration without quercetin when the composition is administered to an animal
• the measurable amount maybe an average of at least about 5%, 10%, 15%, 20%, or more than 20% as described herein
• the physiological compartment is a central nervous system
• the physiological compartment is a renal system
• the physiological compartment is a pancreatic system
• the physiological compartment is a hepatic system
• the physiological compartment is a fetal compartment
• the invention provides a composition containing a calcineurin inhibitor and a Blood- Tissue barrier (BTB) transport protein modulator, where the calcineurin inhibitor is present in an amount sufficient to exert a therapeutic effect and the BTB transport protein modulator is present in an amount sufficient to increase the concentration of the calcineurin inhibitor m a physiological compartment by a measurable amount, compared to the concentration of the calcineurin inhibitor without the BTB transport protein modulator, when the composition is administered to an animal
• physiological compartments include, but are not limited to, blood, liver, lymph nodes, spleen, peyer's patches, intestines, lungs, heart, and kidney.
• a concentration of the calcineurin inhibitor is increased by an average of at least about 5, 10, 15, 20, 25, 30, 35, 40, 45, 50, 55, 60, 65, 70, 75, 80, 85, 90, 95, or more than 95%, compared to the therapeutic effect without the BTB transport protein modulator In some embodiments, concentration of the calcineurin inhibitor is increased by an average of at least about 5%, compared to the concentration of the calcineurin inhibitor without the BTB transport protein modulator , rage ⁇ i ⁇ icd.s> ⁇ aooui , compared to the concentration of the calcmeurin inhibitor without the BTB transport protein modulator In some embodiments, concentration of the calcmeurin inhibitor is increased by an average of at least about 15%, compared to the concentration of the calcmeurin inhibitor without the BTB transport protein modulator In some embodiments, a concentration of the calcmeurin inhibitor is increased by an average of at least about 20%, compared to the concentration of the calcmeurin inhibitor without
• the invention provides a composition containing a calcmeurin inhibitor and a Blood- Tissue barrier (BTB) transport protein modulator, where the calcineu ⁇ n inhibitor is present m an amount sufficient to exert a therapeutic effect and the BTB transport protein modulator is present in an amount sufficient to increase the concentration of the calcmeurin inhibitor m blood by a measurable amount, compared to the concentration of the calcmeurin inhibitor without the BTB transport protein modulator, when the composition is administered to an animal
• BTB Blood- Tissue barrier
• the invention provides a composition containing a calcmeurin inhibitor and a Blood- Tissue barrier (BTB) transport protem modulator, where the calcmeurin inhibitor is present m an amount sufficient to exert a therapeutic effect and the BTB transport protein modulator is present in an amount sufficient to increase the concentration of the calcineurin inhibitor in a lymphoid tissue by a measurable amount, compared to the concentration of the calcmeurin inhibitor without the BTB transport protein modulator, when the composition is administered to an animal
• a lymphoid tissue include but are not limited to, thymus, bone marrow, lymph nodes, spleen, peyer's patches, and lymphatics.
• the invention provides a composition containing a calcineurin inhibitor and a Blood- Tissue barrier (BTB) transport protein modulator, where the calcmeurin inhibitor is present in an amount sufficient to exert a therapeutic effect and the BTB transport protein modulator is present in an amount sufficient to decrease the concentration of the calcineurin inhibitor in a organ, such as kidney, liver, lung or heart, by a measurable amount, compared to the concentration of the calcineurin inhibitor without the BTB transport protein modulator, when the composition is administered to an animal
• BTB Blood- Tissue barrier
• the mvention provides a composition contaming a calcmeurin inhibitor and a Blood- Tissue barrier (BTB) transport protein modulator, where the calcmeurin inhibitor is present in an amount sufficient to exert a therapeutic effect and the BTB transport protein modulator is present in an amount sufficient to decrease the clearance of the calcineurin inhibitor from a physiological compartment where the calcineurin inhibitor exerts a therapeutic effect.
• BTB Blood- Tissue barrier
• An "average" as used herein is preferably calculated in a set of normal human subjects, this set being at least about 3 human subjects, preferably at least about 5 human subjects, preferably at least about 10 human subjects, even more preferably at least about 25 human subjects, and most preferably at least about 50 human subjects
• the invention provides a composition that contains a calcineurin inhibitor and a BTB transport protem modulator, e g a polyphenol such as a flavonoid
• concentration of one or more of the calcmeurin inhibitors and/or BTB transport protein modulator, e g a polyphenol such as a flavonol is less than 100%, 90%, 80%, 70%, 60%, 50%, 40%, 30%, 20%, 19%, 18%, 17%, 16%, 15%,14%, 13%, 12%, 11%, 10%, 9%, 8%, 7%, 6%, 5%, 4%, 3%, 2%, 1%, 0 5%, 04%, 0 3%, 0 2%, 0 1%, 0 09%, 0 08%, 0 07%, 0 06%, 0 05%, 0 04%, 0 03%, 0 02%, 0 01%, 0 009%, 0 008%
• the concentration of one or more of the calcineurin inhibitors and/or BTB transport protein modulator, e.g. a polyphenol such as a flavonoid is greater than 90%, 80%, 70%, 60%, 50%, 40%, 30%, 20%, 19.75%, 19.50%, 19.25% 19%, 18.75%, 18.50%, 18.25% 18%, 17.75%, 17.50%, 17.25% 17%, 16.75%, 16.50%, 16.25% 16%, 15.75%, 15.50%, 15.25% 15%, 14.75%, 14.50%, 14.25% 14%, 13.75%, 13.50%, 13.25% 13%, 12.75%, 12.50%, 12.25% 12%, 11.75%, 11.50%, 11.25% 11%, 10.75%, 10.50%, 10.25% 10%, 9.75%, 9.50%, 9.25% 9%, 8.75%, 8.50%, 8.25% 8%, 7.75%, 7.50%, 7.25% 7%, 6.75%
• the concentration of one or more of the calcineurin inhibitors and/or BTB transport protein modulator, e.g. a polyphenol such as a flavonoid is in the range from approximately 0.0001% to approximately 50%, approximately 0.001% to approximately 40 %, approximately 0.01% to approximately 30%, approximately 0.02% to approximately 29%, approximately 0.03% to approximately 28%, approximately 0.04% to approximately 27%, approximately 0.05% to approximately 26%, approximately 0.06% to approximately 25%, approximately 0.07% to approximately 24%, approximately 0.08% to approximately 23%, approximately 0.09% to approximately 22%, approximately 0.1% to approximately 21 %, approximately 0.2% to approximately 20%, approximately 0.3% to approximately 19%, approximately 0.4% to approximately 18%, approximately 0.5% to approximately 17%, approximately 0.6% to approximately 16%, approximately 0.7% to approximately 15%, approximately 0.8% to approximately 14%, approximately 0.9% to approximately 12%, approximately 1% to approximately 10% w/w, w/v or v/v. v/v.
• the concentration of one or more of the calcineurin inhibitors and/or BTB transport protein modulator, e.g. a polyphenol such as a flavonoid is in the range from approximately 0.001% to approximately 10%, approximately 0.01% to approximately 5%, approximately 0.02% to approximately 4.5%, approximately 0.03% to approximately 4%, approximately 0.04% to approximately 3.5%, approximately 0.05% to approximately 3%, approximately 0.06% to approximately 2.5%, approximately 0.07% to approximately 2%, approximately 0.08% to approximately 1.5%, approximately 0.09% to approximately 1%, approximately 0.1% to approximately 0.9% w/w, w/v or v/v.
• a polyphenol such as a flavonoid
• the amount of one or more of the calcineurin inhibitors and/or BTB transport protein modulator, e.g. a polyphenol such as a flavonoid is equal to or less than 1O g, 9.5 g, 9.0 g, 8.5 g, 8.0 g, 7.5 g, 7.0 g, 6.5 g, 6.0 g, 5.5 g, 5.0 g, 4.5 g, 4.0 g, 3.5 g, 3.0 g, 2.5 g, 2.0 g, 1.5 g, 1.0 g, 0.95 g, 0.9 g, 0.85 g, 0.8 g, 0.75 g, 0.7 g, 0.65 g, 0.6 g, 0.55 g, 0.5 g, 0.45 g, 0.4 g, 0.35 g, 0.3 g, 0.25 g, 0.2 g, 0.15 g, 0.1 g, 0.09 g, 0.08 g, 0.07 g,
• the amount of one or more of the calcineurin inhibitors and/or BTB transport protein modulator, e.g. a polyphenol such as a flavonoid is more than 0.0001 g, 0.0002 g, 0.0003 g, 0.0004 g, 0.0005 g, 0.0006 g, 0.0007 g, 0.0008 g, 0.0009 g, 0.001 g, 0.0015 g, 0.002 g, 0.0025 g, 0.003 g, 0.0035 g, 0.004 g, 0.0045 g, 0.005 g, 0.0055 g, 0.006 g, 0.0065 g, 0.007 g, 0.0075 g, 0.008 g, 0.0085 g, 0.009 g, 0.0095 g, 0.01 g, 0.015 g, 0.02 g, 0.025 g, 0.03 g, 0.035 g, 0.04 g,
• the amount of one or more of the calcineurin inhibitors and/or BTB transport protein modulator, e.g. a polyphenol such as a flavonoid is in the range of 0.0001-10 g, 0.0005-9 g, 0.001-8 g, 0.005-7 g, 0.01-6 g, 0.05-5 g, 0.1-4 g, 0.5-4 g, or 1-3 g.
• compositions of the invention include quercetin and tacrolimus, where quercetin is present in an amount from about 1-1000 mg, or about 10-1000 mg, or about 50-1000 mg, or about 100- 1000 mg, or about 1-500 mg, or about 5-500 mg, or about 50-500 mg, or about 100-500 mg, or about 200-1000 mg, or about 200-800 mg, or about 200-700 mg, or about 10 mg, or about 25 mg, or about 50 mg, or about 100 mg, or about 200 mg, or about 250 mg, or about 300 mg, or about 400 mg, or about 500 mg, or about 600 mg, or about 700 mg, or about 800 mg, or about 900 mg, or about 1000 mg, and tacrolimus is present in an amount from 0.01 to 200 mg, or about 0.1-160 mg, or about 0.1, 0.5, 1, 5, 10, 20, 50, 80, or 160 mg.
• tacrolimus/quercetin is present at about 0.1/50 mg (tacrolimus/quercetin). In some embodiments, tacrolimus is present at about 0.1 mg and the quercetin is present at about 100 mg. In some embodiments, tacrolimus is present at about 0.1 mg and the quercetin is present at about 200 mg. In some embodiments, tacrolimus is present at about 0.1 mg and the quercetin is present at about 300 mg. In some embodiments, tacrolimus is present at about 0.1 mg and the quercetin is present at about 1000 mg. In some embodiments, tacrolimus is present at about 0.5 mg and the quercetin is present at about 100 mg.
• tacrolimus is present at about 0.5 mg and the quercetin is present at about 250 mg. In some embodiments, tacrolimus is present at about 0.5 mg and the quercetin is present at about 500 mg. In some embodiments, tacrolimus is present at about 0.5 mg and the quercetin is present at about 1000 mg. In some embodiments, tacrolimus is present at about 1 mg and the quercetin is present at about 100 mg. In some embodiments, tacrolimus is present at about 1 mg and the quercetin is present at about 250 mg. In some embodiments, tacrolimus is present at about 1 mg and the quercetin is present at about 500 mg.
• tacrolimus is present at about 1 mg and the quercetin is present at about 1000 mg. In some embodiments, tacrolimus is present at about 5 mg and the quercetin is present at about 100 mg. In some embodiments, tacrolimus is present at about 5 mg and the quercetin is present at about 200 mg. In some embodiments, tacrolimus is present at about 5 mg and the quercetin is present at about 300 mg. In some embodiments, tacrolimus is present at about 5 mg and the quercetin is present at about 1000 mg. In some embodiments, tacrolimus is present at about 10 mg and the quercetin is present at about 100 mg.
• tacrolimus is present at about 10 mg and the quercetin is present at about 200 mg. In some embodiments, tacrolimus is present at about 10 mg and the quercetin is present at about 300 mg. In some embodiments, tacrolimus is present at about 10 mg and the quercetin is present at about 1000 mg. In some embodiments, tacrolimus is present at about 15 mg and the quercetin is present at about 100 mg. In some embodiments, tacrolimus is present at about 15 mg and the quercetin is present at about 200 mg. In some embodiments, tacrolimus is present at about 15 mg and the quercetin is present at about 300 mg.
• tacrolimus is present at about 15 mg and the quercetin is present at about 1000 mg.
• tacrolimus can be present at about 1-100 mg/ml, or 1-50 mg/ml, or 1-20 mg/ml, or about 1, 5, 10, or 20 mg/ml and quercetin at about 1-1000 mg/ml, or about 10-1000 mg/ml, or about 50-1000 mg/ml, or about 100-1000 mg/ml, or about 1-500 mg/ml, or about 5-500 mg/ml, or about 50-500 mg/ml, or about 100-500 mg/ml, or about 200-1000 mg/ml, or about 200-800 mg/ml, or about 200-700 mg/ml, or about 10 mg/ml, or about 25 mg/ml, or about 50 mg/ml, or about 100 mg/ml, or about 200 mg/ml, or about 250 mg/ml, or about 300 mg/ml, or a ou mg m m
• a molar ratio of one or more of the calcineu ⁇ n inhibitors to the BTB transport protein modulator e.g. a polyphenol such as a flavonoid can be 0.0001:1 to 1:1.
• the molar ratio of one or more of the calcineu ⁇ n inhibitors to the BTB transport protein modulator e.g.
• a polyphenol such as a flavonoid can be about 0.0001:1 to about 10:1, or about 0.001:1 to about 5:1, or about 0.01:1 to about 5: 1, or about 0.1:1 to about 2:1, or about 0.2:1 to about 2:1, or about 0.5:1 to about 2:1, or about 0.1:1 to about 1:1.
• the molar ratio of one or more of the calcineu ⁇ n inhibitors to the flavonoid can be about O.O3xlO "5 :l, 0.1xl0 "5 :l, 0.04xl0 “3 :l, 0.03xl0 "5 :l, O.O2xlO ⁇ 5 :l, 0.01xl0 ⁇ 3 :l,
• the calcmeurin inhibitor is tacrolimus.
• the flavonoid is quercetm.
• the molar ratio of one or more of the calcineurm inhibitors to the BTB transport protein modulator e.g. a polyphenol such as a flavonoid can be about 0.001 : 1 ,
• the calcmeurin inhibitor is tacrolimus.
• the flavonoid is quercetin.
• the transport protein modulators of the invention are usually administered in the form of pharmaceutical compositions.
• the drugs descnbed above are also administered in the form of pharmaceutical compositions.
• both components may be mixed into a preparation or both components may be formulated into separate preparations to use them in combination separately or at the same time.
• compositions that contain, as the active ingredient, a BTB transport protein modulator or a pharmaceutically acceptable salt and/or coordination complex thereof, and one or more pharmaceutically acceptable excipients, carriers, including inert solid diluents and fillers, diluents, including sterile aqueous solution and various organic solvents, permeation enhancers, solubilizers and adjuvants
• compositions that contain, as the active ingredient, a BTB transport protein modulator or a pharmaceutically acceptable salt and/or coordmation complex thereof, a calcmeurin inhibitor or a pharmaceutically acceptable salt and/or coordination complex thereof, and one or more pharmaceutically acceptable excipients, carriers, including inert solid diluents and fillers, diluents, including sterile aqueous solution and various organic solvents, permeation enhancers, solubilizers and adjuvants.
• a BTB transport protein modulator or a pharmaceutically acceptable salt and/or coordmation complex thereof a calcmeurin inhibitor or a pharmaceutically acceptable salt and/or coordination complex thereof
• excipients including inert solid diluents and fillers, diluents, including sterile aqueous solution and various organic solvents, permeation enhancers, solubilizers and adjuvants.
• the BTB transport protein modulator and/or the calcmeurin inhibitor may be prepared into pharmaceutical compositions in dosages as described herein (see, e.g , Compositions). Such compositions are prepared in a manner well known in the pharmaceutical art.
• compositions for oral administration containing a combination of a calcineurm inhibitor and an agent that reduces or eliminates a side and/or fetal effect of the calcineurm inhibitor, and a pharmaceutical excipient suitable for oral administration.
• the agent that reduces or eliminates the side and/or fetal e ec o e ca cmeurm in i i or is a ranspor pro ein mo u a or, e g a po yp enol sucn as a navonoi, as described elsewhere herein
• the invention provides a solid pharmaceutical composition for oral administration containing
• the composition further contains: (iv) an effective amount of a second calcmeu ⁇ n inhibitor.
• the pharmaceutical composition may be a liquid pharmaceutical composition suitable for oral consumption.
• the calcineurm inhibitor is tacrolimus. In some embodiments, the calcineurm inhibitor is a tacrolimus analog In some embodiments, the calcineurm inhibitor is CsA. In some embodiments, the agent capable of reducing or eliminating one or more side effects of the calcmeu ⁇ n inhibitor is a BTB transport protein modulator, e g , a BTB transport protein activator In some embodiments, the agent capable of reducing or eliminating one or more side effects of the calcmeu ⁇ n inhibitor is a polyphenol, e g., a flavonoid such as a flavonol. [00238] In some embodiments, the invention provides a solid pharmaceutical composition for oral administration containing
• the composition further contains (iv) an effective amount of a second calcineurm inhibitor.
• the pharmaceutical composition may be a liquid pharmaceutical composition suitable for oral consumption
• the invention provides a solid pharmaceutical composition for oral administration containing
• the composition further contains (iv) an effective amount of a second calcineurm inhibitor
• the pharmaceutical composition may be a liquid pharmaceutical composition suitable for oral consumption.
• the invention provides a solid pharmaceutical composition for oral administration containing an effective amount of tacrolimus, an amount of quercetin that is effective in reducing or eliminating a side effect of tacrolimus, and a pharmaceutically acceptable excipient
• the invention provides a liquid pharmaceutical composition for oral administration containing an effective amount of tacrolimus, i limus, ana a pnamid u y acceptable excipient
• the invention provides a solid pharmaceutical composition for oral administration containing tacrolimus at about 0 01-160 mg, quercetm at about 10-1000 mg and a pharmaceutically acceptable excipient
• the invention provides a liquid pharmaceutical composition for oral administration containing tacrolimus at about 0.1-200 mg/ml, quercetm at about 10-1000 mg/ml and a pharmaceutically acceptable excipient
• compositions of the invention suitable for oral administration can be presented as discrete dosage forms, such as capsules, cachets, or tablets, or liquids or aerosol sprays each containing a predetermined amount of an active ingredient as a powder or in granules, a solution, or a suspension in an aqueous or non-aqueous liquid, an oil-in-water emulsion, or a water- m-oil liquid emulsion.
• dosage forms can be prepared by any of the methods of pharmacy, but all methods mclude the step of bringing the active ingredient into association with the carrier, which constitutes one or more necessary ingredients.
• compositions are prepared by uniformly and intimately admixing the active ingredient with liquid carriers or finely divided solid earners or both, and then, if necessary, shaping the product mto the desired presentation
• a tablet can be prepared by compression or molding, optionally with one or more accessory ingredients.
• Compressed tablets can be prepared by compressing in a suitable machine the active ingredient in a free-flowing form such as powder or granules, optionally mixed with an excipient such as, but not limited to, a binder, a lubricant, an inert diluent, and/or a surface active or dispersing agent Molded tablets can be made by molding in a suitable machine a mixture of the powdered compound moistened with an inert liquid diluent
• This invention further encompasses anhydrous pharmaceutical compositions and dosage forms comp ⁇ sing an active ingredient, since water can facilitate the degradation of some compounds
• water may be added (e.g , 5%) in the pharmaceutical arts as a means of simulating long-term storage in order to determine characteristics such as shelf-life or the stability of formulations over time.
• Anhydrous pharmaceutical compositions and dosage forms of the invention can be prepared using anhydrous or low moisture containing ingredients and low moisture or low humidity conditions
• Pharmaceutical compositions and dosage forms of the invention which contain lactose can be made anhydrous if substantial contact with moisture and/or humidity during manufacturing, packaging, and/or storage is expected
• An anhydrous pharmaceutical composition may be prepared and stored such that its anhydrous nature is maintained
• anhydrous compositions may be packaged using materials known to prevent exposure to water such that they can be mcluded m suitable formulary kits
• suitable packaging include, but are not limited to, hermetically sealed foils, plastic or the like, unit dose containers, blister packs, and strip packs.
• An active ingredient can be combined in an intimate admixture with a pharmaceutical carrier according to conventional pharmaceutical compounding techniques
• the earner can take a wide variety of forms depending on the form of preparation desired for administration
• any of the usual pharmaceutical media can be employed as earners, such as, for example, water, glycols, oils, alcohols, flavoring agents, preservatives, coloring agents, and the like in the case of oral liquid preparations (such as suspensions, solutions, and elixirs) or aerosols; or carriers such as starches, sugars, micro-crystalline cellulose, diluents, granulating agents, lubricants, binders, and disintegrating agents can be used m the case of oral solid preparations, in some embodiments without employing the use of lactose
• suitable carriers include powders, capsules, and tablets, with the solid oral preparations If desired, tablets can be coated by standard aqueous or nonaqueous techniques m ers sui a e
• Disintegrants may be used in the compositions of the invention to provide tablets that disintegrate when exposed to an aqueous environment Too much of a disintegrant may produce tablets which may disintegrate in the bottle. Too little may be insufficient for disintegration to occur and may thus alter the rate and extent of release of the active mgredient(s) from the dosage form Thus, a sufficient amount of disintegrant that is neither too little nor too much to detrimentally alter the release of the active ⁇ ngredient(s) may be used to form the dosage forms of the compounds disclosed herein The amount of disintegrant used may vary based upon the type of formulation and mode of administration, and may be readily discernible to those of ordinary skill in the art About 0 5 to about 15 weight percent of disintegrant, or about 1 to about 5 weight percent of disintegrant, may be used in the pharmaceutical composition Disintegrants that can be used to form pharmaceutical compositions and dosage forms of the invention include, but are not limited to, agar-agar, algmic acid, calcium carbonate, microcrystallme
• the essential active ingredient therein may be combined with various sweetening or flavoring agents, coloring matter or dyes and, if so desired, emulsifying and/or suspending agents, together with such diluents as water, ethanol, propylene glycol, glycerin and various combinations thereof
• the tablets can be uncoated or coated by known techniques to delay disintegration and absorption in the gastrointestinal tract and thereby provide a sustained action over a longer period
• a time delay material such as glyceryl monostearate or glyceryl distearate can be employed
• Formulations for oral use can also be presented as hard gelatin capsules wherein the active ingredient is mixed with an inert solid diluent, for example, calcium carbonate, calcium phosphate or kaolin, or as soft gelatin capsules wherein the active ingredient is mixed with water or an oil medium, for example, peanut oil, liquid paraffin or olive oil
• Surfactant which can be used to form pharmaceutical compositions and dosage forms of the invention include, but are not limited to, hydrophilic surfactants, lipophilic surfactants, and mixtures thereof That is, a mixture of hydrophilic surfactants may be employed, a mixture of lipophilic surfactants may be employed, or a mixture of at least one hydrophilic surfactant and at least one lipophilic surfactant may be employed l ⁇ , wniie smraoie li surfactants may generally have an HLB value of or less than about 10.
• HLB hydrophilic-lipophilic balance
• surfactants with lower HLB values are more lipophilic or hydrophobic, and have greater solubility in oils, while surfactants with higher HLB values are more hydrophilic, and have greater solubility in aqueous solutions
• Hydrophilic surfactants are generally considered to be those compounds having an HLB value greater than about 10, as well as amonic, cationic, or zwitterionic compounds for which the HLB scale is not generally applicable
• lipophilic (i.e , hydrophobic) surfactants are compounds having an HLB value equal to or less than about 10
• HLB value of a surfactant is merely a rough guide generally used to enable formulation of industrial, pharmaceutical and cosmetic emulsions
• Hydrophilic surfactants may be either ionic or non-iomc Suitable ionic surfactants include, but are not limited to, alkylammonium salts, fusidic acid salts, fatty acid derivatives of amino acids, oligopeptides, and polypeptides; glyceride derivatives of amino acids, oligopeptides, and polypeptides, lecithins and hydrogenated lecithins, lysolecithins and hydrogenated lysolecithins, phospholipids and derivatives thereof, lysophospholipids and de ⁇ vatives thereof; carnitine fatty acid ester salts; salts of alkylsulfates, fatty acid salts, sodium docusate, acyl lactylates, mono- and di-acetylated tartaric acid esters of mono- and di-glyce ⁇ des; succinylated mono- and di- glycendes; citric acid esters of mono
• preferred ionic surfactants include, by way of example lecithins, lysolecithin, phospholipids, lysophospholipids and derivatives thereof, carnitine fatty acid ester salts, salts of alkylsulfates, fatty acid salts, sodium docusate, acyl lactylates, mono- and di-acetylated tartaric acid esters of mono- and di-glyce ⁇ des, succinylated mono- and di-glycendes; citric acid esters of mono- and di-glyce ⁇ des, and mixtures thereof
• Ionic surfactants may be the ionized forms of lecithin, lysolecithin, phosphatidylcholine, phosphatidylethanolamme, phosphatidylglycerol, phosphatide acid, phosphatidylse ⁇ ne, lysophosphatidylcholine, lysophosphatidylethanolamine, lysophosphatidylglycerol, lysophosphatidic acid, lysophosphatidylserine, PEG- phosphatidylethanolamine, PVP-phosphatidylethanolamine, lactyhc esters of fatty acids, stearoyl-2-lactylate, stearoyl lactylate, succinylated monoglyce ⁇ des, mono/diacetylated tartaric acid esters of mono/diglyce ⁇ des, citric acid esters of mono/diglyce ⁇ des, cholylsarcosme, ca
• Hydrophilic non-ionic surfactants may include, but not limited to, alkylglucosides, alkylmaltosides, alkylthioglucosides, lauryl macrogolglycerides, polyoxyalkylene alkyl ethers such as polyethylene glycol alkyl ethers, polyoxyalkylene alkylphenols such as polyethylene glycol alkyl phenols, polyoxyalkylene alkyl phenol fatty acid esters such as polyethylene glycol fatty acids monoesters and polyethylene glycol fatty acids diesters, polyethylene glycol glycerol fatty acid esters, polyglycerol fatty acid esters; polyoxyalkylene sorbitan fatty acid esters such as polyethylene glycol sorbitan fatty acid esters, hydrophilic transesterification products of a polyol with at least one member of the group consisting of glycerides, vegetable oils, hydrogenated vegetable oils, fatty acids, and sterols, polyoxyethylene sterol
• Suitable lipophilic surfactants include, by way of example only: fatty alcohols; glycerol fatty acid esters; acetylated glycerol fatty acid esters; lower alcohol fatty acids esters; propylene glycol fatty acid esters; sorbitan fatty acid esters; polyethylene glycol sorbitan fatty acid esters; sterols and sterol derivatives; polyoxyethylated sterols and sterol derivatives; polyethylene glycol alkyl ethers; sugar esters; sugar ethers; lactic acid derivatives of mono- and di-glycerides; hydrophobic transesterification products of a polyol with at least one member of the group consisting of glycerides, vegetable oils, hydrogenated vegetable oils, fatty acids and sterols; oil-soluble vitamins/vitamin derivatives; and mixtures thereof.
• preferred lipophilic surfactants include glycerol fatty acid esters, propylene glycol fatty acid esters, and mixtures thereof, or are hydrophobic transesterification products of a polyol with at least one member of the group consisting of vegetable oils, hydrogenated vegetable oils, and triglycerides.
• the composition may include a solubilizer to ensure good solubilization and/or dissolution of the calcineurin inhibitor and/or BTB transport protein modulator (e.g., flavonol) and to minimize precipitation of the calcineurin inhibitor and/or BTB transport protein modulator (e.g., flavonol).
• a solubilizer may also be added to increase the solubility of the hydrophilic drug and/or other components, such as surfactants, or to maintain the composition as a stable or homogeneous solution or dispersion.
• solubilizers include, but are not limited to, the following: alcohols and polyols, such as ethanol, isopropanol, butanol, benzyl alcohol, ethylene glycol, propylene glycol, butanediols and isomers thereof, glycerol, pentaerythritol, sorbitol, mannitol, transcutol, dimethyl isosorbide, polyethylene glycol, polypropylene glycol, polyvinylalcohol, hydroxypropyl methylcellulose and other cellulose derivatives, cyclodextrins and cyclodextrin derivatives; ethers of polyethylene glycols having an average molecular weight of about 200 to about 6000, such as tetrahydrofurfuryl alcohol PEG ether (glycofurol) or methoxy PEG ; amides and other nitrogen- containing compounds such as 2-pyrrolidone, 2-piperidone,
• solubihzers include sorbitol, glycerol, triacetm, ethyl alcohol, PEG-400, glycofurol and propylene glycol
• the amount of solubihzer that can be included is not particularly limited
• the amount of a given solubilizer may be limited to a bioacceptable amount, which may be readily determined by one of skill in the art In some circumstances, it may be advantageous to include amounts of solubihzers far in excess of bioacceptable amounts, for example to maximize the concentration of the drug, with excess solubilizer removed prior to providing the composition to a patient using conventional techniques, such as distillation or evaporation
• the solubilizer can be in a weight ratio of 10%, 25%, 50%, 100%, or up to about 200% by weight, based on the combined weight of the drug, and other excipients If desired, very small amounts of solubilizer may also be used, such as 5%, 2%, 1 % or even less.
• the solubilizer may be present in an amount of about 1 % to about 100%, more typically about 5% to about 25% by weight
• the composition can further include one or more pharmaceutically acceptable additives and excipients
• additives and excipients include, without limitation, detackifiers, anti-foaming agents, buffering agents, polymers, antioxidants, preservatives, chelating agents, viscomodulators, tonicif ⁇ ers, flavorants, colorants, odorants, opacifiers, suspending agents, binders, fillers, plasticizers, lubricants, and mixtures thereof
• an acid or a base may be incorporated into the composition to facilitate processing, to enhance stability, or for other reasons
• pharmaceutically acceptable bases include amino acids, ammo acid esters, ammonium hydroxide, potassium hydroxide, sodium hydroxide, sodium hydrogen carbonate, aluminum hydroxide, calcium carbonate, magnesium hydroxide, magnesium aluminum silicate, synthetic aluminum silicate, synthetic hydrocalcite, magnesium aluminum hydroxide, dnsopropylethylamme, ethanolamme, ethylenediamine, t ⁇ ethanolamme, triethylamine, trnsopropanolamine, t ⁇ methylamine, tris(hydroxymethyl)aminomethane (TRIS) and the like
• bases that are salts of a pharmaceutically acceptable acid such as acetic acid, acrylic acid, adipic acid, alginic acid, alkanesulfonic acid, amino acids, ascorbic acid, benzoic acid, boric acid, butyric acid, carbonic acid,
• armaceu ica composi ions or iniec ion n some em o imen s, e inven ion provides a pharmaceutica composition for injection containing a combination of a calcineurin inhibitor and an agent that, e g , reduces or eliminates a side and/or fetal effect of the calcineurin inhibitor, and a pharmaceutical excipient suitable for injection
• a calcineurin inhibitor e.g , reduces or eliminates a side and/or fetal effect of the calcineurin inhibitor
• Aqueous solutions m salme are also conventionally used for injection Ethanol, glycerol, propylene glycol, liquid polyethylene glycol, and the like (and suitable mixtures thereof), cyclodext ⁇ n derivatives, and vegetable oils may also be employed
• the proper fluidity can be maintained, for example, by the use of a coatmg, such as lecithin, by the maintenance of the required particle size in the case of dispersion and by the use of surfactants
• the prevention of the action of microorganisms can be brought about by various antibacterial and antifungal agents, for example, parabens, chlorobutan
• Sterile injectable solutions are prepared by incorporating the transport protem modulator and/or the calcineurin inhibitor in the required amount in the appropriate solvent with various other ingredients as enumerated above, as required, followed by filtered sterilization
• dispersions are prepared by incorporating the various sterilized active ingredients into a sterile vehicle which contains the basic dispersion medium and the required other ingredients from those enumerated above
• the preferred methods of preparation are vacuum-drymg and freeze-drymg techniques which yield a powder of the active ingredient plus any additional desired ingredient from a previously sterile-filtered solution thereof
• compositions for topical e g . transdermaD delivery
• the invention provides a pharmaceutical composition for transdermal delivery containing a combination of a calcineurin inhibitor and an agent that, e g , reduces or eliminates a side and/or fetal effect of the calcineurin inhibitor, and a pharmaceutical excipient suitable for transdermal delivery
• the agent that e.g , reduces or eliminates the side and/or fetal effect of the calcineurin inhibitor is a BTB transport protein modulator, e g a polyphenol such as a flavonol, as described elsewhere herein
• Components and amounts of agents in the compositions are as described herein
• compositions of the present invention can be formulated into preparations in solid, semi-solid, or liquid forms suitable for local or topical administration, such as gels, water soluble jellies, creams, lotions, suspensions, foams, powders, slurries, ointments, solutions, oils, pastes, suppositories, sprays, emulsions, saline solutions, dimethylsulfoxide (DMSO)-based solutions
• DMSO dimethylsulfoxide
• carriers with higher densities are capable of providing an area with a prolonged exposure to the active ingredients
• a solution formulation may provide more immediate exposure of the active ingredient to the chosen area
• the pharmaceutical compositions also may comprise suitable solid or gel phase carriers or excipients, which are compounds that allow increased penetration of, or assist in the delivery of, therapeutic molecules across the stratum corneum permeability barrier of the skin
• suitable solid or gel phase carriers or excipients which are compounds that allow increased penetration of, or assist in the delivery of, therapeutic molecules across the stratum corneum permeability barrier of the skin
• these penetration-enhancing molecules include, but are not limited to, humectants (e g , urea), glycols (e g , propylene glycol), alcohols (e g , ethanol), fatty acids (e g , oleic acid), surfactants (e g , isopropyl my ⁇ state and sodium lauryl sulfate), pyrrohdones, glycerol monolaurate, sulfoxides, terpenes (e g , menthol), amines, amides, alkanes, alkanols
• the invention provides a transdermal patch incorporating a BTB transport protein modulator, e.g., a polyphenol such as a flavonoid (e.g., quercetin).
• a transdermal patch incorporating a BTB transport protein modulator e.g., a polyphenol such as a flavonoid (e.g., quercetin) in combination with a calcmeurin inhibitor, e.g. tacrolimus
• transdermal patches for the delivery of pharmaceutical agents is well known in the art. See, e.g., U.S. Pat. Nos. 5,023,252, 4,992,445 and 5,001,139. Such patches may be constructed for continuous, pulsatile, or on demand delivery of pharmaceutical agents.
• compositions for inhalation include solutions and suspensions in pharmaceutically acceptable, aqueous or organic solvents, or mixtures thereof, and powders.
• the liquid or solid compositions may contain suitable pharmaceutically acceptable excipients as described supra.
• the compositions are administered by the oral or nasal respiratory route for local or systemic effect.
• Compositions m preferably pharmaceutically acceptable solvents may be nebulized by use of inert gases. Nebulized solutions may be inhaled directly from the nebulizing device or the nebulizing device may be attached to a face mask tent, or intermittent positive pressure breathing machine.
• Solution, suspension, or powder compositions may be administered, preferably orally or nasally, from devices that deliver the formulation in an approp ⁇ ate manner.
• Other pharmaceutical compositions Pharmaceutical compositions may also be prepared from compositions described herein and one or more pharmaceutically acceptable excipients suitable for sublingual, buccal, rectal, intraosseous, intraocular, intranasal, epidural, or intraspinal administration. Preparations for such pharmaceutical compositions are well-known in the art.
• kits include an agent as described herein, in suitable packaging, and written material that can include instructions for use, discussion of clinical studies, listing of side effects, and the like.
• the kit may further contain a calcmeurin inhibitor.
• the calcineurin inhibitor and the agent are provided as separate compositions in separate containers within the kit.
• the calcmeurin inhibitor and the agent are provided as a single composition within a container in the kit.
• Suitable packaging and additional articles for use e g., measuring cup for liquid preparations, foil wrapping to minimize exposure to air, and the like) are known in the art and may be included in the kit
• the invention provides methods, including methods of treatment, methods of decreasing or increasing the concentration of a substance in a physiological compartment, methods of enhancing a therapeutic e ec o a su s ance, me o s o rug was -ou , an me o s or i en i ying mo u a ors oi tsioo ⁇ - 1 issue carrier transport proteins
• animal or "animal subject” as used herein includes humans as well as other mammals
• the methods generally involve the administration of one or more drugs for the treatment of one or more diseases
• Combinations of agents can be used to treat one disease or multiple diseases or to modulate the side-effects of one or more agents in the combination
• treating includes achieving a therapeutic benefit and/or a prophylactic benefit
• therapeutic benefit is meant eradication or amelioration of the underlying disorder being treated
• a therapeutic benefit is achieved with the eradication or amelioration of one or more of the physiological symptoms associated with the underlying disorder such that an improvement is observed in the patient, notwithstanding that the patient may still be afflicted with the underlying disorder
• the compositions may be administered to a patient at risk of developing a particular disease, or to a patient reporting one or more of the physiological symptoms of a disease, even though a diagnosis of this disease may not have been made
• the invention provides a method of treating a condition by administering to an animal suffering from the condition an effective amount of a calcineurin inhibitor and an amount of a BTB transport protein activator sufficient to reduce or eliminate a side effect of the calcineurin inhibitor
• the activator reduces or eliminates a plurality of side effects of the calcineurin inhibitor
• the invention provides a method of treating a condition by administering to an animal suffering from the condition an effective amount of a calcineurin inhibitor and an amount of a BTB transport protein activator sufficient to increase a therapeutic effect of the calcineurin inhibitor
• the activator increases a plurality of therapeutic effects of the calcineurin inhibitor
• the invention provides a method of treating a condition by administering to an animal suffering from the condition an effective amount of a calcineurin inhibitor and an amount of a BTB transport protein activator sufficient to decrease or increase the concentration of the calcineurin inhibitor in a physiological compartment
• the animal is a mammal, e g , a human
• the invention provides a method of treating a condition by administering to an animal suffering from the condition an effective amount of a calcineurin inhibitor and an amount of a BTB transport protein activator sufficient to increase a therapeutic effect of a calcineurin inhibitor in a physiological compartment J00291]
• the calcineurin inhibitor and the BTB transport protein activator are co-administered "Coadministration,” “administered in combination with,” and their grammatical equivalents, as used herein, encompasses administration of two or more agents to an animal so that both agents and/or their metabolites are present in the animal at the same time
• Co-admmistration includes simultaneous administration in separate compositions, administration at different times in separate compositions, or administration in a composition in which both agents are present
• the BTB transport protein activator and the calcineurin inhibitor are administered m a single composition
• the calcineurin inhibitor and the BTB transport protein activator are admixed
• Administration of the calcineurin inhibitor and the agent, e g., that reduces or eliminates at least one side effect of the calcineurin inhibitor may be by any suitable means If the agents are administered as separate compositions, they may be administered by the same route or by different routes If the agents are administered m a single composition, they may be administered by any suitable route In some embodiments, the agents are administered as a single composition by oral administration In some embodiments, the agents are administered as a single composition by transdermal administration In some embodiments, the agents are administered as a single composition by injection
• the agent that reduces or eliminates a side effect of a calcineurin inhibitor is a BTB transport protein modulator, BTB transport protein modulators are as described herein.
• a polyphenol is used in some embodiments, a flavonoid is used in some embodiments, the flavonoid is quercetin, isoquercetin, flavon, chrysin, apigemn, rhoifolin, diosmm, galangm, fisetm, mo ⁇ n, rutin, kaempferol, myricetin, taxifohn, na ⁇ ngemn, narmgm, hesperetin, hespe ⁇ din, chalcone, phloretin, phlo ⁇ zdin, gemstein, biochanm A, catechin, or epicatechm.
• the flavonoid is quercetin, kaempferol, or galangin. In some embodiments, the flavonoid is quercetin Dosages are as provided for compositions Typically, the daily dosage of the BTB transport protein modulator will be about 0 5-100 mg/kg
• the calcineurin inhibitor may be any calcineurin inhibitor described herein. In some embodiments, the calcineurin inhibitor is tacrolimus or a tacrolimus analog, as described herein
• the methods of the invention may be used for treatment of any suitable condition, e g , organ transplant, an autoimmune disease, and an inflammatory disease, where one or more calcineurin inhibitors are used that have CNS effects
• the methods of the invention include the treatment of organ transplant recipient to prevent organ rejection by administering to an animal in need of treatment an effective amount of a calcineurin inhibitor, such as tacrolimus, and an effective amount of an agent that reduces or eliminates a side effect of the calcineurin inhibitor.
• a calcineurin inhibitor such as tacrolimus
• an agent that reduces or eliminates a side effect of the calcineurin inhibitor include, but are not limited to, kidney transplant, pancreas transplant, liver transplant, heart transplant, lung transplant, intestine transplant, pancreas after kidney transplant, and simultaneous pancreas-kidney transplant
• the methods of the invention include the treatment of an autoimmune disease by administering to an animal in need of treatment an effective amount of a calcineurin inhibitor, such as tacrolimus, and an effective amount of an agent that reduces or eliminates a side effect of the calcineurin inhibitor
• a calcineurin inhibitor such as tacrolimus
• an agent that reduces or eliminates a side effect of the calcineurin inhibitor examples include, but are not limited to, Lupus nephritis, actopic dermatitis, and psoriasis
• the methods of the invention include the treatment of inflammatory conditions rejection by administering to an animal in need of treatment an effective amount of a calcineurin inhibitor, such as tacrolimus, and an effective amount of an agent that reduces or eliminates a side effect of the calcmeurm inhibitor
• inflammatory conditions include, but are not limited to, asthma, vulvar lichen sclerosis, chronic allergic contact dermatitis, eczema, vitiligo and ulcerative colitis - .
• en a ca cineurin in i i or an an agen as escri e erein are use in combination, any suitable ra io o the two agents, e g , molar ratio, wt/wt ration, wt/volume ratio, or volume/volume ratio, as described herein, may be used
• the invention further provides methods of reversing one or more side effects of a calcineurin inhibitor by administering a BTB transport protein activator to an animal that has received an amount of the calcineurm inhibitor sufficient to produce one or more side effects
• the methods are especially useful in a situation where it is desired to rapidly reverse one or more side effects of a calcineurin inhibitor, e g , in an overdose situation
• Any suitable BTB transport protein described herein may be used
• the invention provides a method for reversing a side effect of a calcineurin inhibitor m a human by administering to the human an amount of a BTB transport protein modulator sufficient to partially or completely reverse a side effect of the calcineurin inhibitor, where the human has received an amount of said calcineurm inhibitor sufficient to produce a side effect.
• the human has received an overdose of the calcmeu ⁇ n inhibitor producing the side effect
• the individual continues to experience peripheral effects of the calcineurin inhibitor
• the BTB transport protein modulator is a polyphenol, such as a flavonoid
• the flavonoid is quercetin, isoquercetin, flavon, chrysin, apigenin, rhoifohn, diosmin, galangm, fisetin, mono, rutin, kaempferol, myricetm, taxifohn, na ⁇ ngenin, naringin, hesperetin, hespendm, chalcone, phloretin, phlo ⁇ zdin, gemstein, biochanin A, catechin, or epicatechin
• the flavonoid is quercetin
• the flavonoid will be administered by injection, e g , intravenously or ln
• the invention provides a method for increasing a therapeutic effect of a calcineurin inhibitor in a human by administering to the human an amount of a BTB transport protein modulator sufficient to partially or completely reverse a side effect of the calcineurin inhibitor, where the human has received an amount of said calcineurin inhibitor sufficient to produce a therapeutic effect
• the BTB transport protein modulator is a polyphenol, such as a flavonoid
• the flavonoid is quercetin, isoquercetin, flavon, chrys
• the invention provides a method for decreasing or increasing the concentration of a calcineurin inhibitor in a physiological compartment in a human by administering to the human an amount of a BTB transport protein modulator sufficient to decrease or increase the concentration of a calcineurin inhibitor in a physiological compartment, where the human has received an amount of said calcineurin inhibitor sufficient for treatment.
• the invention provides a method for decreasing or increasing the concentration of tacrolimus or a tacrolimus analog in a physiological compartment in a human by administering to the human an amount of a BTB transport protein modulator sufficient to decrease or increase the concentration of tacrolimus or a tacrolimus analog in a physiological compartment, where the human has received an amount of tacrolimus or a tacrolimus analog sufficient for treatment.
• the BTB transport protein modulator is a polyphenol, such as a flavonoid.
• the flavonoid is quercetin, isoquercetin, flavon, chrysin, apigenin, rhoifolin, diosmin, galangin, fisetin, morin, rutin, kaempferol, myricetin, taxifolin, naringenin, naringin, hesperetin, hesperidin, chalcone, phloretin, phlorizdin, genistein, biochanin A, catechin, or epicatechin.
• the flavonoid is quercetin.
• the flavonoid will be administered by injection, e.g., intravenously or intraperitoneally, in a dose sufficient to increase a therapeutic effect of the calcineurin inhibitor.
• a dose in a human can be, e.g., about 0.1-100 g, or about 0.5-50 g, or about 1-20 g, or 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 12, 14, 16, 18, or 20 g.
• the dose can be 0.01-1.5 g/kg.
• the dose can be 0.02 - 0.5 g/kg.
• the dose can be 0.15 - 0.5 g/kg.
• a further aspect of the invention is a method of identifying a transport protein modulator.
• a drug is administered in an appropriate animal model in the presence and absence of a test compound and the concentration of the drug in a biological sample are measured.
• the test compound is identified as a transport protein modulator if the concentration of the drug in the biological sample is lower in the presence of the test compound.
• the biological sample may be intraventricular samples, amniotic fluid, chorionic samples or brain parenchymal samples.
• the animal model may be a rodent, such as mice or rats, or a primate, horse, dog, sheep, goat, rabbit, or chicken. In other embodiments, the animal model possesses a mutant form of a blood brain transporter.
• the methods involve the administration of an agent as described herein.
• administration will be described in terms of reduction of a side effect of a calcineurin inhibitor. It is understood that the administration apply equally to other methods described herein.
• a calcineurin inhibitor that produces a side effect is administered in combination with an agent that reduces the side effects of the calcineurin inhibitor.
• other agents are also administered, e.g., other calcineurin inhibitors.
• two or more agents may be coadministered in any suitable manner, e.g., as separate compositions, in the same composition, by the same or by different routes of administration.
• the agent that reduces or eliminates a side effect of a calcineurin inhibitor is administered in a single dose. This may be the case, e.g., in wash-out methods where the agent is introduced into an animal to quickly lower the side effect of a calcineurin inhibitor already present in the body.
• ⁇ ums ra ion wi e y injec ion, e g in ravenous injec ion, in or er o in ro uce e agent quicxiy rtowever
• other routes may be used as appropriate
• a single dose of an agent that reduces or eliminates a side effect of a calcineurm inhibitor may also be used when it is administered with the calcineu ⁇ n inhibitor (e g , a calcineu ⁇ n inhibitor that produces a CNS effect) for treatment of an acute condition
• the agent that reduces or eliminates a side effect of a substance and/or calcineurm inhibitor is administered in multiple doses Dosing may be about once, twice, three times, four times, five times, six times, or more than six times per day Dosing may be about once a month, once every two weeks, once a week, or once every other day
• the calcineurm inhibitor is tacrolimus
• the calcineurm inhibitor and the transport protein activator are administered together about once per day to about 6 times per day
• the administration of the calcineurm inhibitor and the transport protein activator continues for less than about 7 days
• the administration continues for more than about 6, 10, 14, 28 days, two months, six months, or one year In some cases, continuous dosing is achieved and maintained as long as necessary, e g , organ transplant patient
• an agent of the invention is administered for more than 1, 2, 3, 4, 5, 6, 7, 14, or 28 days In some embodiments, an agent of the invention is administered for less than 28, 14, 7, 6, 5, 4, 3, 2, or 1 day In some embodiments, an agent of the invention is administered chronically on an ongoing basis, e g , for the treatment of chronic effects
• An effective amount of a transport protein modulator and an effective amount of a calcineurm inhibitor may be administered m either single or multiple doses by any of the accepted modes of administration of agents having similar utilities, including rectal, buccal, intranasal and transdermal routes, by lntra-arte ⁇ al injection, intravenously, lntrape ⁇ toneally, parenterally, intramuscularly, subcutaneously, orally, topically, as an inhalant, or via an impregnated or coated device such as a stent, for example, or an artery-inserted cylindrical polymer [003]
• uai y ose range may depend on the form of flavonoid, e.g., the carbohydrate moieties attached to the flavonoid, and/or factors with which the flavonoid is administered, as described herein.
• the serum half-life for, e.g., quercetin, is about 19- 25 hours, so single dose accuracy is not crucial.
• a BTB transport modulator e.g., a flavonoid such as quercetin
• a composition that comprises one or more calcineurin inhibitors
• the calcineurin inhibitor has a shorter half-life than BTB transport modulator unit dose forms of the calcineurin inhibitor and the BTB transport modulator may be adjusted accordingly.
• quercetin is given in a composition also containing, e.g., calcineurin inhibitor
• a typical unit dose form is, e.g., 50 mg calcineurin inhibitor /100 mg quercetin, or 50 mg calcineurin inhibitor /500 mg quercetin. See e.g., Compositions.
• unit dose forms of the BTB transport modulator may be adjusted such that the side effect of the calcineurin inhibitor are reduced without a substantial reduction of the therapeutic effect.
• tacrolimus Due to intersubject variability in tacrolimus pharmacokinetics, individualization of dosing regimen is necessary for optimal therapy.
• the dose of tacrolimus is adjusted daily to achieve a trough concentration of 15 to 20 and approximately 10 ng/mL in the first 2 weeks and the subsequent 2 weeks, respectively.
• a blood sample is collected before the morning dose for measuring the concentrations.
• the tacrolimus whole-blood concentration is measured using the microparticle enzyme immunoassay method, which is known in the art.
• Q 100 - 500mg per gel capsule is compounded and supplied to all subjects. In some trials, placebo capsules are also compounded. Subjects are instructed to complete daily dia ⁇ es for 7 days and continue their baseline me ica ions an regu ar ac ivi ies n approxima e y e ay, ey are as e o egin twice ⁇ any ⁇ osmg o
• Example 2 Human study of the effects of Quercetin (Q) and Tacrolimus on atopic dermatitis patient
• Inclusion criteria include patients who suffered from actopic dermatitis and are under PROTOPIC Ointment (tacrolimus) and that demonstrate neurotoxic episodes such as seizures, tremors, abnormal vision etc Patients can apply PROTOPIC Ointment 0 03% or PROTOPIC Ointment 0 01% to the affected skin twice daily
• Q 100 - 500mg per gel capsule is compounded and supplied to all subjects In some trials, placebo capsules are also compounded Subjects are instructed to complete daily diaries for 7 days and continue their baseline medications and regular activities On approximately the 7th day, they are asked to begin twice daily dosing of 2 Q (200 - lOOOmg) capsules (total daily dose of Q, 200 - 2000mg), or an equivalent dosage of placebo, preferably double-blmded (if placebo is used). Diaries are then completed for 7 days.
• Spleens were collected at 4 hr after administration of FK506 for use in the in vitro mixed lymphocyte reaction (MLR) and Con A assays. In addition to treated Lewis rats, spleens were collected from 5 Brown Norway rats (not treated) which were used for the in vitro assay.
• MLR mixed lymphocyte reaction
• spleens were collected from 5 Brown Norway rats (not treated) which were used for the in vitro assay.
• CM normal rat serum (from Lewis rats), 2 mM
• BN splenocytes were pooled and irradiated with 1,500-2,000 rad (cesium source) before use.
• Control wells for each cell suspension contained 10 5 responders alone in medium and 10 pooled, irradiated stimulators alone in medium (separate wells). For a positive proliferative response, each responder (10 ) was treated with 2.5 ⁇ g/ml Con A.
• FK 506 inhibited MLR.
• FK 506 exhibited a stronger inhibitory effect at lower R:S ratios (See Figures).
• LNS 0694 increased FK 506 inhibitory effect in a dose-dependent manner. As shown in Figure 7, LNS
• 0694 also increased FK 506 inhibitory effect when the LEW, responders were activated with Con A.
• tacrolimus inhibited Con A-mduced proliferation in a dose dependent manner in cultures at high and low cell concentration Quercetm had no significant effect in the response of cells to Con A at a high or low cell concentration
• Figures 10 and 11 show the effect of quercetin and tacrolimus on response of mouse spleen cells to LPS at a high (1 6 xlO 6 cells/well) and low (8 x 10 5 cells/well) cell concentration, respectively.
• tacrolimus inhibited LPS-induced proliferation m a dose dependent manner both in high and low cell concentration cultures. Quercetin had no significant effect in the response of cells to LPS at a high or low cell concentration.
• Figures 12 and 13 show the effect of vehicle treatment on mitogen responses at a high (1.6 xlO 6 cells/well) and low (8 x 10 s cells/well) cell concentration, respectively.
• Figures 12 and 13 show no significant difference between no vehicle and either DMSO or captisol vehicle for either mitogen
• Spleen cells were treated with Con A in the presence of vehicle, tacrolimus, quercetm or two different concentrations of tacrolimus (10 ⁇ 82 and 10 8 5 M) and increasing doses of quercetin at a high cell concentration
• FIG 16 shows no significant difference between cultures treated with tacrolimus and cultures treated with tacrolimus and quercetin. Quercetm did not impair tacrolimus induced cell suppression in vitro at either concentration of tacrolimus. There was no significance difference between the effect of quercetin on tacrolimus induced cell suppression in vitro at the different concentrations used for quercetin. The same results were observed in cultures with low cell concentration (figure 15).
• Example 5 BTB transport protein modulator increase peripheral bioavailability and decrease the volume of distribution of Tacrolimus
• the brains were harvested from one subset of 3 rats per group at 2 hr after FK506 treatment.
• Plasma Blood Sample Collection Whole blood was collected from the retro-orbital sinus under 60:40
• Drug levels were determined in collected whole blood samples using a bioanalytical method developed to detect parent drug levels.
• Figure 17 shows the plasma concentration of FK 506 at different time points after 1 mg/kg i.v. administration alone or in combination with i.p, administration of different doses of LNS 0694
• Results in figures 16 and 17 demonstrate that LNS 0694 increases the peripheral bioavailability of FK506 in a dose dependent manner. xamp e anspor r i u or in re ri era ioav i i i y anu ⁇ ecrease me v ⁇ iume o distribution of Tacrolimus
• Rats 8-9 weeks-old rats, e.g., Lewis and Brown Norway male rats, can be used. General procedures for animal care and housing are in accordance with the National Research Council (NRC) Guide for the Care and Use of Laboratory Animals (1996) and the Animal Welfare Standards incorporated in 9 CFRPart 3, 1991.
• NRC National Research Council
• Treatment Rats are treated as i.v with FK506 and i.p. with Quercetin at two different concentrations, 500mg/kg or 200 mg/kg. Subsets of 3 Lewis rats per group are used for blood sampling at each time point (Groups 2-5) at described in the table below.
• livers, pancreas, kidneys, and intestines are harvested from one subset of 3 rats per group at 2 hr after
• Plasma Blood Sample Collection Whole blood is collected from the retro-orbital sinus under 60:40 CO 2 :O 2 anesthesia using EDTA as the anticoagulant. Sample collection is performed at 9 time points: 5, 15, and 30 min and
• the first 2 samples are collected under anesthesia, after which the animal regained consciousness and is retained until the next collection interval.
• the third/last sample is also collected under anesthesia, however the animal is euthanatized prior to anesthetic recovery.
• Drug levels are determined in collected samples using bioanalytical methods developed to detect parent drug levels known in the art.
• Results are shown in Figures 18, 19 and 20.
• esu s gure s ows a e ca cu a e - in ini y increases a er i.p. a minis ra ion o different doses of Quercetin in a dose dependent manner when compared with the control group.
• Figure 19 demonstrates an interaction at the higher 200 mg/kg quercetin dose including change in the Vd, AUC, Cmax and clearance. At this higher concentration of quercetin the Cmax and AUC increase while the Vd and clearance decrease.
• Figure 20 shows the whole blood concentration of FK 506 at different time points after i.v. administration alone or in combination with i.p. administration of different doses of Quercetin.

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